Karaarslan, Ahmet Adnan; Acar, Nihat; Aycan, Hakan; Sesli, Erhan
Nailing of tibial shaft fractures is considered the gold standard surgical method by many surgeons. The aim of this retrospective study was to investigate and compare the clinical outcome of tibial shaft fractures treated with intramedullary nails compressed by proximal tube and conventional intramedullary interlocking nails. Fifty-seven patients with tibial shaft fractures, treated with intramedullary nails compressed by proximal tube (n = 32) and the conventional interlocking nails (n = 25), were reviewed. All fractures except for one were united without any additional surgical intervention in the proximal compression tube nail group, whereas in the conventional interlocking nail group, six patients needed dynamization surgery (p = 0.005) and three cases of nonunion were recorded. In the proximal compression tube nail group, faster union occurred in 20 ± 2 (16-24) weeks (mean ± SD; range) without failure of locking screws and proximal nail migration, whereas in the conventional interlocking nail group, union occurred in 22 ± 2.5 (17-27) weeks (p = 0.001) with two failures of locking screws and two proximal nail migration. The proximal compression tube nail system is safer than the conventional nailing methods for the treatment for transverse and oblique tibial shaft fractures with a less rate of nonunion, proximal locking screw failure and proximal nail migration.
Jakma, Tijs; Reynders-Frederix, Peter; Rajmohan, Rai
Intramedullary nailing of proximal tibial fractures can be difficult when using the standard entry portal. We evaluated the suprapatellar portal, using a midline quadriceps tendon incision, to perform intramedullary nailing of the tibia. Seven patients were treated with this adaptation of the standard intramedullary nailing procedure. An arthroscopy was done before and after the nailing procedure. No special equipment was used to perform the intramedullary nailing. We evaluated the handling and necessary modifications of the standard intramedullary technique to introduce the locked tibial nail through the suprapatellar approach. We found this technique not necessarily more difficult than the standard intramedullary nailing of the tibia through the infrapatellar entry portal. Although the patients did not complain of patellofemoral discomfort after the suprapatellar nailing, definitive scuffing of the cartilage in the lower part of the femoral trochlea was visible. Introduction of a locked tibial nail via the suprapatellar approach was found to be possible and even advantageous for some complex upper tibial shaft fractures in compromised limbs. Some possible downsides of this approach need to be taken into account but, in some cases, they can be outweighed by the benefits.
Behera, Prateek; Aggarwal, Sameer; Kumar, Vishal; Kumar Meena, Umesh; Saibaba, Balaji
Fractures of the tibia are one of the most commonly seen orthopedic injuries. Most of them result from a high velocity trauma. While intramedullary nailing of tibial diaphyseal fractures is considered as the golden standard form of treatment for such cases, many metaphyseal and metaphyseal-diaphyseal junction fractures can also be managed by nailing. Maintenance of alignment of such fractures during surgical procedure is often challenging as the pull of patellar tendon tends to extend the proximal fragment as soon as one flexes the knee for the surgical procedure. Numerous technical modifications have been described in the literature for successfully nailing such fractures including semi extended nailing, use of medial plates and external fixators among others. In this study, it was aimed to report two cases in which we used our ingenious method of applying external fixator for maintaining alignment of the fracture and aiding in the entire process of closed intramedullary nailing of metaphyseal tibial fractures by the conventional method. We were able to get good alignment during and after the closed surgery as observed on post-operative radiographs and believe that further evaluation of this technique may be of help to surgeons who want to avoid other techniques.
Bible, Jesse E; Choxi, Ankeet A; Dhulipala, Sravan C; Evans, Jason M; Mir, Hassan R
Limited information exists to define standard tibial radiographs. The purpose of this study was to define new landmarks on the proximal tibia for standard anteroposterior and lateral radiographs. In 10 cadaveric knees, fibular head bisection was considered the anteroposterior image, and femoral condyle overlap the lateral image. In another 10 knees, a "twin peaks" anteroposterior view, showing the sharpest profile of the tibial spines, was used. The "flat plateau" lateral image was obtained by aligning the femoral condyles then applying a varus adjustment with overlap of the tibial plateaus. Medial peritendinous approaches were performed, and an entry reamer used to open the medullary canal. A priori analysis showed good to excellent intra-/inter-observer reliability with the new technique (intra-class correlation coefficient ICC 0.61-0.90). The "twin peaks" anteroposterior radiograph was externally rotated 2.7±2.1° compared to the standard radiograph with fibular head bisection. Portal position and incidence of damage to intra-articular structures did not significantly differ between groups (P>.05). The "twin peaks" anteroposterior view and "flat plateau" lateral view can safely be used for nail entry portal creation in the anatomic safe zone. Tibia-based radiographic referencing is useful for intramedullary nailing cases in which knee or proximal tibiofibular joint anatomy is altered.
Valls-Mellado, M; Martí-Garín, D; Fillat-Gomà, F; Marcano-Fernández, F A; González-Vargas, J A
We describe a case of a severely comminuted type iiia open tibial fracture, with distal loss of bone stock (7 cm), total involvement of the tibial joint surface, and severe instability of the fibular-talar joint. The treatment performed consisted of thorough cleansing, placing a retrograde reamed calcaneal-talar-tibial nail with proximal and distal blockage, as well as a fibular-talar Kirschner nail. Primary closure of the skin was achieved. After 3 weeks, an autologous iliac crest bone graft was performed to fill the bone defect, and the endomedullary nail, which had protruded distally was reimpacted and dynamized distally. The bone defect was eventually consolidated after 16 weeks. Currently, the patient can walk without pain the tibial-astragal arthrodesis is consolidated. Copyright © 2013 SECOT. Published by Elsevier Espana. All rights reserved.
... All Site Content AOFAS / FootCareMD / Treatments Proximal Tibial Bone Graft Page Content What is a bone graft? Bone grafts may be needed for various ... the proximal tibia. What is a proximal tibial bone graft? Proximal tibial bone graft (PTBG) is a ...
Gómez-Benito, María José; Fornells, Pere; García-Aznar, José Manuel; Seral, Belén; Seral-Iñnigo, Fernando; Doblaré, Manuel
We compared, via a computational model, the biomechanical performance of reamed versus unreamed intramedullary tibial nails to treat fractures in three different locations: proximal, mid-diaphyseal, and distal. Two finite element models were analyzed for the two nail types and the three kinds of fractures. Several biomechanical variables were determined: interfragmentary strains in the fracture site, von Mises stresses in nails and bolts, and strain distributions in the tibia and fibula. Although good mechanical stabilization was achieved in all the simulated fractures, the best results were obtained in the proximal fracture for the unreamed nail and in the mid-diaphyseal and distal fractures for the reamed nail. The interlocking bolts, in general, were subjected to higher stresses in the unreamed tibial nail than in the reamed one; thus the former stabilization technique is more likely to fail due to fatigue.
Zelle, Boris A; Boni, Guilherme; Hak, David J; Stahel, Philip F
Reamed locked intramedullary nailing remains the standard treatment for displaced tibial shaft fractures. Supra-patellar tibial nailing in the semiextended position has been suggested as a safe and effective surgical technique that allows mitigating certain challenges of the standard subpatellar approach. Suprapatellar nailing seems to facilitate achieving and maintaining fracture reduction, particularly in proximal third tibia fractures. Preliminary investigations have suggested that this technique is associated with a low rate of complications, including a reduced incidence of postoperative anterior knee pain. Further clinical investigations are necessary to establish overall complication rates and long-term subjective outcomes.
Franke, J; Hohendorff, B; Alt, V; Thormann, U; Schnettler, R
Intramedullary nailing is the standard procedure for surgical treatment of closed and Gustilo-Anderson Grade I-II° open fractures of the tibial shaft. The use of intramedullary nailing for the treatment of proximal metaphyseal tibia fractures is frequently followed by postoperative malalignment, whereas plate osteosynthesis is associated with higher rates of postoperative infection. Intramedullary nailing of tibial fractures is generally performed through an infrapatellar approach. The injured extremity must be positioned at a minimum of 90° of flexion in the knee joint to achieve optimal exposure of the correct entry point. The tension of the quadriceps tendon causes a typical apex anterior angulation of the proximal fragment. The suprapatellar approach improves reduction of the fracture and reduces the occurrence of malalignment during intramedullary nailing of extra-articular proximal tibial fractures. The knee is positioned in 20° of flexion to neutralise traction forces secondary to the quadriceps muscle, thus preventing an apex anterior angulation of the proximal fragment. An additional advantage of the technique is that it allows the surgeon to avoid or minimise further soft tissue damage because of the distance between the optimal incision point and the usual area of soft tissue damage.
Coury, John G; Lum, Zachary C; O'Neill, Nicholas P; Gerardi, Joseph A
There has been a trend towards flexible intramedullary nailing for unstable tibial shaft fractures in the pediatric population, traditionally, utilizing a 2-incision technique with passage of one nail medially and one nail laterally. Our study aims to compare a single incision approach for flexible nailing of unstable tibial shaft fractures in pediatric patients to the traditional 2-incision approach. Patients were selected for operative fixation if they had a length unstable tibial shaft fracture confirmed by fluoroscopy. Exclusion criteria included length stable tibial fractures that could undergo nonoperative treatment. Single incision technique utilized the medial incision only. Patients were monitored in the hospital for one postoperative day and followed up at 4 week, 8 week, and 12 week marks. Radiographic analysis was performed to evaluate for malunion or nonunion. Operative times, infection rates and complications were recorded and analyzed. All patients achieved complete fracture healing at the 12-week follow up. There were no delayed unions, nonunions or malunions in either treatment group. Single medial incision for tibial flexible nails had equivalent outcomes with no difference in primary healing rate, malunion or nonunion rate when compared to the dual incision technique.
Chmielnicki, M; Prokop, A
Tibial shaft fractures are among the most common long bone fractures in humans. The incidence is 1-2 per 100,000. The gold standard of treatment for AO type 42 A-C fractures is a locking intramedullary nail. The development of new implants has extended the indications for this minimally invasive technique, so that now AO types 41 and 43 can also be treated with special nails. Fixed-angle screw anchors increase primary stability and supplemental locking devices located proximally and distally extend the spectrum of use to metaphyseal fractures. The cannulated Targon TX titanium nail can be introduced, either with or without reaming. Using an operative video, the treatment of a tibial fracture with an intramedullary nail is demonstrated in stages and the operative steps further illustrated on artificial bone. Georg Thieme Verlag KG Stuttgart · New York.
Ward, William G; Cooper, Joshua M
A patient with a cemented centrally located intramedullary tibial nail that occluded the proximal tibial canal underwent knee reconstruction with a total knee design utilizing a custom hollow tibial stem. In this oncology case, a rotating-hinge knee design was used that incorporates an intra-articular inverted post-in-channel central rotational post design. This design allowed for a rather straightforward reconstruction that functioned well for 3 years. Although rarely encountered, utilization of a hollow-stemmed tibial total knee component may allow salvage of an extremity with central occlusion of the proximal tibial canal.
Rueger, J M; Rücker, A H; Hoffmann, M
Closed tibial shaft fractures are the domain of intramedullary nailing. With the introduction of new nail designs and technologies, even small, dislocated distal fragments can be anatomically aligned and safely fixed. Unsolved or to a lesser degree controlled are the problems of distal locking in the freehand technique, which can still be difficult and can lead to a significant radiation exposure, and how to control very short proximal tibial fragments in metaphyseal tibial fractures or tibial segmental fractures, where the proximal fracture line also runs through the metaphysis.By using a suprapatellar approach, i.e. a skin incision proximal to the patella with an entry point into the tibial bone from within the knee at the same site as for a standard infrapatellar approach, and then nailing the tibia in a semi-extended position, i.e. the knee is only flexed 10-20°, the intraoperative dislocation of a short proximal fragment can be avoided. The main indications for semi-extended tibial nailing are a short diaphyseal fragment in an isolated tibial shaft fracture, a segmental fracture where the proximal fracture line is metaphyseal and in patients where infrapatellar soft tissues are compromised.The use of the electromagnetic guidance system SureShot® generates reliable and reproducible results, reduces the operating time and is independent from radiation for distal locking.
Salem, Khaled Hamed
Unreamed nailing has gained acceptance in the treatment of diaphyseal long bone fractures, especially in cases with polytrauma or high-energy injuries. Its application in distal tibial fractures, however, remains controversial. In this study, 101 distal tibial fractures treated using closed unreamed nailing were reviewed after a mean follow-up of 32 months. There were 59 type A und 42 type B fractures. The most common fracture pattern was the A1 spiral fracture (n = 40) followed by the B2 wedge fracture (n = 18). Intra-articular extension was encountered in 14 cases. One-fourth of the patients (n = 24) had open injuries. Forty-seven patients had additional injuries, and nearly one-third of them were polytraumatised. Union occurred after a mean time of 23.9 (range, 11-134) weeks. There were 13 cases of delayed union and seven non-unions; all healed eventually with additional surgery in only six fractures. Malunion was seen in 12 cases (five valgus, two varus and five external torsion), ten of which were associated with unplated fibular fractures. Three fractures (two open) were treated for deep infection. The most common complication seen was fatigue failure of the locking screws (27 cases). Unreamed nailing of distal tibial fractures is associated with a rather high rate of bone healing complications and locking screw failure. The decision for its use in the notoriously challenging fractures of this segment should be critically considered.
Intramedullary nailing of the tibia with suprapatellar entry and semi-extended positioning makes it technically easier to nail the proximal and distal fractures. The purpose of this article was to describe a simple method for suprapatellar nailing (SPN). A step-by-step run through of the surgical technique is described, including positioning of the patient. There are as yet only a few clinical studies that illustrate the complications with this method, and there has been no increased frequency of intraarticular damage. Within the body of the manuscript, information is included about intraarticular damage and comments with references about anterior knee pain.
Intramedullary nailing of the tibia with suprapatellar entry and semi-extended positioning makes it technically easier to nail the proximal and distal fractures. The purpose of this article was to describe a simple method for suprapatellar nailing (SPN). A step-by-step run through of the surgical technique is described, including positioning of the patient. There are as yet only a few clinical studies that illustrate the complications with this method, and there has been no increased frequency of intraarticular damage. Within the body of the manuscript, information is included about intraarticular damage and comments with references about anterior knee pain. PMID:27340503
Wagner, Mark; Liu, Qi; Ellis, Thomas J
Comminuted tibial shaft fractures are traditionally treated with statically locked intramedullary nailing and protected weight bearing until fracture callous is evident. The purpose of this study was to demonstrate that a simulation of immediate full weight bearing following intramedullary nailing of these fractures does not result in implant failure.A comminuted fracture model was created using 2 pieces of polyvinyl chloride (PVC) pipe. Ten-millimeter-diameter tibial nails (Synthes, Paoli, Pennsylvania; Styker, Mahwah, New Jersey; Zimmer, Warsaw, Indiana; Smith & Nephew, Memphis, Tennessee) were inserted within the PVC pipe and secured proximally and distally with 2 or 3 locking bolts. The constructs were cycled in axial compression for 500,000 cycles or until implant failure. The tests were conducted using a modified staircase method (200 N per step), and the fatigue strength was identified for each of the tibial nail designs. When 2 interlocking bolts were placed proximally and distally, the fatigue strength was between 900 and 1100 N for the Stryker nail, 1100 and 1300 N for the Zimmer nail, 1200 and 1400 N for the Synthes nail, and 1400 and 1600 N for the Smith & Nephew nail. Adding a third interlocking bolt proximally and distally to the Smith & Nephew nail increased the fatigue strength by 13% to between 1700 and 1900 N. In all cases, implant failures occurred through the proximal or distal interlocking bolts.Biomechanical tests suggest that current tibial nail designs may permit immediate full weight bearing of comminuted tibial shaft fractures with minimal risk of implant failure. This may facilitate mobilization in the early postoperative period, especially in the multiply injured patient.
Zelle, Boris A; Boni, Guilherme
Statically locked, reamed intramedullary nailing remains the standard treatment for displaced tibial shaft fractures. Establishing an appropriate starting point is a crucial part of the surgical procedure. Recently, suprapatellar nailing in the semi-extended position has been suggested as a safe and effective surgical technique. Numerous reduction techiques are available to achieve an anatomic fracture alignment and the treating surgeon should be familiar with these maneuvers. Open reduction techniques should be considered if anatomic fracture alignment cannot be achieved by closed means. Favorable union rates above 90 % can be achieved by both reamed and unreamed intramedullary nailing. Despite favorable union rates, patients continue to have functional long-term impairments. In particular, anterior knee pain remains a common complaint following intramedullary tibial nailing. Malrotation remains a commonly reported complication after tibial nailing. The effect of postoperative tibial malalignment on the clinical and radiographic outcome requires further investigation.
Amarathunga, Jayani P; Schuetz, Michael A; Yarlagadda, Prasad Kvd; Schmutz, Beat
Intramedullary nailing is the standard fixation method for displaced diaphyseal fractures of the tibia. An optimal nail design should both facilitate insertion and anatomically fit the bone geometry at its final position in order to reduce the risk of stress fractures and malalignments. Due to the nonexistence of suitable commercial software, we developed a software tool for the automated fit assessment of nail designs. Furthermore, we demonstrated that an optimised nail, which fits better at the final position, is also easier to insert. Three-dimensional models of two nail designs and 20 tibiae were used. The fitting was quantified in terms of surface area, maximum distance, sum of surface areas and sum of maximum distances by which the nail was protruding into the cortex. The software was programmed to insert the nail into the bone model and to quantify the fit at defined increment levels. On average, the misfit during the insertion in terms of the four fitting parameters was smaller for the Expert Tibial Nail Proximal bend (476.3 mm(2), 1.5 mm, 2029.8 mm(2), 6.5 mm) than the Expert Tibial Nail (736.7 mm(2), 2.2 mm, 2491.4 mm(2), 8.0 mm). The differences were statistically significant (p ≤ 0.05). The software could be used by nail implant manufacturers for the purpose of implant design validation.
Zelle, Boris A
Intramedullary nail fixation remains the standard treatment for displaced tibial shaft fractures. Establishing an appropriate starting point remains a crucial step in the surgical procedure. Tibial nailing using an infrapatellar starting point with the knee flexed over a radiolucent triangle has been established as a widely-used standard technique. Tibial nail insertion with the knee in the semi-extended position was introduced with the goal to counteract post-operative procurvatum deformities that frequently have been reported as a common problem in proximal third tibial shaft fractures. Early reports on tibial nailing in the semi-extended position used a knee arthrotomy in order to establish the proximal tibial starting point. Recent technological advances have provided the surgical community with instrumentation systems that allow for tibial nailing in the semi-extended position using a suprapatellar portal with nail insertion through the patellofemoral joint. Preliminary clinical studies have suggested favorable outcomes that can be achieved with this technique. This article provides a description of the surgical technique and a review of the currently available evidence.
Kuhn, S; Appelmann, P; Pairon, P; Gruszka, D; Rommens, P M
PURPOSE OF THE STUDY The treatment of distal tibial fractures requires a stable fixation while minimizing the secondary trauma to the soft tissues by the surgical approach and implant. The experimental Retrograde Tibial Nail is currently investigated as a minimally invasive alternative to plating and antegrade nailing. The purpose of this study was to evaluate the surgical feasibility in a cadaver model for all distal tibial fracture types generally considered treatable by nailing. MATERIAL AND METHODS Five different fracture types (AO/OTA 43-A1/A2/A3 and 43-C1/C2) were created on separate cadaveric limbs. In simple fractures (AO/OTA 43-A1/A2/A3) primary nailing was performed. In intraarticular fractures (AO/OTA 43-C1/2) reduction of the articular block and lag screw fixation was performed before nailing. Intraoperative complications, quality of reduction, fluoroscopy duration and operative time were evaluated. RESULTS Retrograde intramedullary nailing is feasible in simple fracture types by closed manual reduction and percutaneous reduction forceps. Retrograde nailing is possible in fractures with simple intraarticular involvement after primary lag screw fixation. The duration of surgery averaged 51.8 minutes (range 40-62 min). No major complications occurred during nailing. CONCLUSIONS The minimally invasive retrograde nail combines a minimally invasive local osteosynthesis with the ability to adequately fix extraarticular and simple intraarticular distal tibial fractures. The results suggests that retrograde tibia nailing is a promising new concept for the treatment of distal tibia fractures. Key words: minimally invasive surgery, tibia, metaphyseal fractures, intramedullary nailing, retrograde nailing.
Woyski, Dustin; Emerson, Jason
Fractures of the tibial shaft in patients with ipsilateral total knee arthroplasty are rare but difficult to treat. Nonoperative treatment of these fractures with casting or bracing limits weight bearing for an extended period and can result in unacceptable malalignment. Operative fixation with plate and screws also limits early weight bearing and requires healing of soft tissue that is of poor quality. The authors present a method of internal fixation that uses a standard intramedullary tibial nail and suprapatellar instrumentation. This method can easily be performed, avoids the tibial baseplate, and does not require alteration of the instrumentation or intramedullary nail.
Ghafil, Dior; Ackerman, Pieter; Baillon, Renaud; Verdonk, Rene; Delince, Philippe
Interlocking intramedullary nailing is currently the preferred treatment for most tibial fractures requiring operative treatment, with good results and a relatively low complication rate as reported in large clinical series. However, vascular and neurological complications caused by interlocking screws have been reported. In addition, insertion of distal interlocking screws can be technically demanding and may entail substantial exposure. We present the results with an expandable self-locking nail in the management of 52 AO type A and B tibial shaft fractures. The mean time to union was 15.8 weeks and the rate of union was 98%. The average surgical time was 60 minutes. Complications were those usually seen in diaphysis nailing and no complication was noted during nail expansion. Interlocking screws are not necessary, which reduces the risk of iatrogenic lesions. The expandable nail allows effective management of AO type A and B diaphyseal fractures of the tibia, a lower radiation exposure and shorter operative time.
Chen, Chun-Yu; Lin, Kai-Cheng; Yang, Shan-Wei; Tarng, Yih-Wen; Hsu, Chien-Jen; Renn, Jenn-Huei
Chronic anterior knee pain is the most common complication after tibial nail insertion. Its etiology remains unknown, and multifactorial sources have been suggested. The authors believe that nail prominence and the insertion point of the nail are important in the development of anterior knee pain. The purpose of this retrospective study was to evaluate the roles of the insertion point and nail prominence in anterior knee pain after tibial intramedullary nailing using a transtendinous approach and a common nail type. A total of 108 patients with tibial shaft fractures underwent reamed intramedullary nailing using a transtendinous approach between 2006 and 2009. Mean follow-up was 26.8±5.0 months. A visual analog scale (0-100) was used to estimate anterior knee pain severity while patients performed 7 activities retrospectively. Radiographic assessments, including nail prominence and insertion point, were performed. Sixty (55.6%) patients experienced knee pain (group P) and 48 (44.4%) did not (group N). Significant differences were not found between the groups with respect to demographics, nail diameters, or fracture classifications. Less superior and more anterior nail prominences in radiographic assessments were significantly associated with anterior knee pain. When the insertion point was over the bottom half of the anterior cortex, the influence of anterior nail prominence was more obvious. Nail removal resulted in diminished pain during the 7 assessed activities. Nail insertion should be over the bottom half of the anterior cortex, with minimal anterior nail prominence. If anterior knee pain occurs, removal of the nail should be considered.
Kim, Seung-Ju; Cielo Balce, Gracia; Huh, Young-Jae; Song, Sang-Yoon; Song, Hae-Ryong; Kim, Seung-Ju
Tibial lengthening over an intramedullary (IM) device is associated with a risk of deep intramedullary infection; there is so far no guideline for decision making between early removal and delayed removal of the nail. Tibial lengthening over an intramedullary nail/Rush pin was performed in 118 limb segments (63 patients) from 2004 to 2008 in our institution. Fifty five patients had bilateral tibial lengthening. Ninety nine of the 118 segments went on to healing without infection, while 13 segments developed superficial infection and 6 segments developed deep infection. Among 6 patients with deep infection, 4 patients underwent early removal of the nail when deep infection signs and symptoms occurred and 2 patients underwent delayed removal of the nail at 11 months. The 6 segments with deep infection differed significantly with respect t to the callus pattern (p < 0.05) and density (p = 0.0001) from those without infection and with superficial infection. In this small sugroup, removal of the nail was delayed in two patients as there was visible callus bridging at more than one cortex, and deep infection subsided after local drainage.
Chen, Daoyun; Chen, Jianmin; Jiang, Yao; Liu, Fanggang
Leg discrepancy is common after poliomyelitis. Tibial lengthening is an effective way to solve this problem. It is believed lengthening over a tibial intramedullary nail can provide a more comfortable lengthening process than by the conventional technique. However, patients with sequelae of poliomyelitis typically have narrow intramedullary canals allowing limited space for inserting a tibial intramedullary nail and Kirschner wires. To overcome this problem, we tried using humeral nails instead of tibial nails in the lengthening procedure. In this study, we used humeral nails in 20 tibial lengthening procedures and compared the results with another group of patients who were treated with tibial lengthening over tibial intramedullary nails. The mean consolidation index, percentage of increase and external fixation index did not show significant differences between the two groups. However, less blood loss and shorter operating time were noted in the humeral nail group. More patients encountered difficulty with the inserted intramedullary nail in the tibial nail group procedure. The complications did not show a statistically significant difference between the two techniques on follow-up. In conclusion, we found the humeral nail lengthening technique was more suitable in leg discrepancy patients with sequelae of poliomyelitis.
Darabos, Nikica; Bajs, Ivana Dovzak; Rutić, Zeljko; Darabos, Anela; Poljak, Damir; Dobsa, Jasminka
Our aim was to determine the possible relationship between anterior knee pain (AKP) and nail position marked as a distance from tip of nail to tibial plateau (NP) and to the tuberositas tibiae (NT). Nail position has an influence on anterior knee pain after tibial intramedullary nailing. We evaluated postoperative outcome results of 50 patients in the last 3 years with healed fractures initially treated with intramedullary (IM) reamed nails with 2 or 3 interlocking screws on both parts of the nail and with the use of medial paratendinous incision for nail entry portal. Patients marked a point on the visual analog scale (VAS) that corresponded to the level of postoperative AKP felt. Two groups of patients were formed on the basis of AKP (pain level was neglected): groups A and B, with and without pain, respectively. The difference between the two groups concerning NP measurements was statistically significant (p < 0.05), but not concerning NT measurements at the p < 0.05 level. Patients were classified by pain with high accuracy (98%) according to a classification tree. Symptoms of AKP did not appear if the tip of the nail position was more than 6.0 mm from the NP and more than 2.6 mm from the NT. However, for better evaluation of these results it will be necessary to examine a larger number of postoperative patients with AKP.
Salem, Khaled Hamed
Unreamed nails have revolutionised the treatment of tibial shaft fractures. Many authors, however, have reported increasing bone healing complications with these implants. Unfortunately, few studies have addressed the factors affecting bone healing after unreamed tibial nailing. One-hundred and sixty tibial fractures in 158 patients (mean age 39.5 years) fixed using unreamed nails were reviewed. There were 78 AO type-A, 65 type-B and 17 type-C fractures (115 closed and 45 open fractures). Twelve patient, injury and surgery variables were analysed for their influence on fracture healing. Union occurred in all fractures after a mean time of 24.3 weeks. Additional surgery to achieve union, apart from dynamisation, was done in nine (6%) cases. The most important variables affecting healing were the mechanism of trauma (p=0.005), fracture site gap (p=0.01), degree of comminution (p=0.0003), associated soft tissue injuries (p=0.02) and the time to dynamisation (p=0.0001). High-energy trauma and fracture comminution have a negative impact on bone union and require close follow-up. It is essential to avoid distraction over three millimetres with unreamed nailing. Dynamisation is advised within ten weeks in axially stable fractures to encourage bone healing and avoid failure of the locking screws.
Scolaro, John A; Broghammer, Francis H; Donegan, Derek J
The optimal treatment strategy for distal tibia fractures, especially those with intraarticular extension, remains controversial. Although open reduction and internal fixation with a plate and screw device is commonly performed for these injuries, the risk of soft tissue complications using this approach is significant. Staged treatment protocols and alternative means of fixation have been proposed to address these undesired events. Although potentially more technically demanding than fixation of diaphyseal or extraarticular tibial fractures, intramedullary nail (IMN) fixation of simple intraarticular distal tibia fractures is a viable treatment alternative with unique advantages. This article presents a review of the literature and rationale for intramedullary tibial nail fixation of simple intraarticular distal tibia fractures and a surgical approach commonly utilized for successful implementation.
Kuhn, Sebastian; Appelmann, Philipp; Pairon, Philip; Mehler, Dorothea; Rommens, Pol M
Displaced distal tibia fractures require stable fixation while minimizing secondary damage to the soft tissues by the surgical approach and implants. Antegrade intramedullary nailing has become an alternative to plate osteosynthesis for the treatment of distal metaphyseal fractures over the past two decades. While retrograde intramedullary nailing is a standard procedure in other long bone fractures, only few attempts have been made on retrograde nailing of tibial fractures. The main reasons are difficulties of finding an ideal entry portal and the lack of an ideal implant for retrograde insertion. The Retrograde Tibial Nail (RTN) is a prototype intramedullary implant developed by our group. The implant offers double proximal and triple distal interlocking with an end cap leading to an angle-stable screw-nail construct of the most distal interlocking screw. Its design meets the requirements of a minimally invasive surgical approach, with a stable fracture fixation by multiple locking options. The 8mm diameter curved nail, with a length of 120 mm, is introduced through an entry portal at the medial malleolus. We see possible indications for the RTN in far distal tibial shaft fractures, distal extraarticular metaphyseal tibial fractures and in distal tibia fractures with simple extension into the ankle joint when the nail is combined lag screw fixation. A biomechanical comparison of the current RTN prototype against antegrade nailing (Expert Tibial Nail, Synthes(®), ETN) was performed. Both implants were fixed with double proximal and triple distal interlocking. Seven biomechanical composite tibiae were treated with either osteosynthesis techniques. A 10mm defect osteotomy 40 mm proximal to the joint line served as an AO 43-A3 type distal tibial fracture model. The stiffness of the implant-bone constructs was measured under low and high extra-axial compression (350 and 600 N) and under torsional load (8 Nm). Results show a comparable stability during axial loading
Aggerwal, Sameer; Soni, Ashwani; Saini, Uttam-C; Gahlot, Nitesh
Intramedullary interlocking nailing is a gold standard for treatment of tibial shaft fractures. Bending of a nail secondary to trauma is a rare complication, which may be encountered in healed or unhealed tibial shaft fractures. Removal of such bent nail is always a challenge. We reported this case to discuss various techniques for removal of bent nails and to share our experience in removing a bent tibial intramedullary nail in a 30-year-old man, who was admitted in our department with re-fracture of the right tibial shaft due to a roadside accident two years after the initial surgical treatment. The intramedullary nail, bent by 30 degrees and visible on anterioposterior as well as on lateral radiographs, was firstly weakened by partially cutting the convex wall, then straightened by applying external force, and finally removed by using the standard nail removal method.
Park, Hoon; Ryu, Keun Jung; Kim, Hyun Woo; Hwang, Jin Ho; Han, Joon Woo; Lee, Dong Hoon
During tibial lengthening, the soft tissues of the posterolateral compartment produce distraction-resisting forces causing valgus angulation. Although this occurs with the classic Ilizarov method, whether a valgus deformity develops with the lengthening over nail (LON) technique is questioned, because the intramedullary nail is thought to resist deforming forces and adequately maintain alignment of the distracted bone. The purposes of this study were to (1) determine the amount of valgus deviation during tibial lengthening with the LON technique; and (2) analyze the factors that may be associated with valgus deviation with the LON technique. Between June 2009 and September 2013, we performed 346 tibial lengthenings using the LON technique, lengthening and then nail technique, or lengthening with an intramedullary lengthening device. Sixty patients (120 tibias) who underwent bilateral lower leg lengthening with the LON technique were enrolled in this retrospective study. To limit the number of variables, we analyzed only the right tibia in all patients (60 tibias). The mean followup was 42 months (range, 26-71 months). The mean age of the patients was 25 years (range, 18-40 years). There were 36 male and 24 female patients. The mean final length gain was 67 ± 9 mm. The mean time for distraction was 100 ± 25 days. The overall valgus deviation was assessed by measuring the change in the medial proximal tibial angle and mechanical femorotibial angle on radiographs obtained before and after surgery and after completion of lengthening. Several demographic, surgical, and distraction-related variables were considered possible factors to prevent valgus deviation: proximal fixation method; presence of a blocking screw; diameter and length of the intramedullary nail; degree of nail insertion; length of the nail in the distal segment after completion of distraction; final length gain; and patient's BMI. During the period studied, the blocking screw was to maintain the
Triantafillou, Konstantinos; Barcak, Eric; Villarreal, Arturo; Collinge, Cory; Perez, Edward
We hypothesize that the anatomic center of the distal tibia is just lateral and anterior to the center of the distal tibia articular surface in the coronal and sagittal planes respectively, and that placement of the nail along this axis results in improved rates of malalignment when treating distal tibia fractures. Retrospective study SETTING:: One level I and one level II trauma center PATIENTS/PARTICIPANTS:: 203 distal tibia fractures treated with IMN (primary cohort) whose main fracture line extended within 5 cm of the plafond to evaluate the rate of malalignment with distal nail placement. Additionally, we retrospectively reviewed a secondary cohort of 15 patients with proximal tibia fractures treated with intramedullary nailing for evaluation of passive anatomic distal nail position. Primary malalignment ≤ 5 degrees on the anteroposterior (AP), mortise, and lateral planes were evaluated in distal tibia fractures on perioperative radiographs. Primary Cohort: 85 patients met inclusion criteria for evaluation in the coronal plane. Overall malalignment in the coronal plane was 17.6%. There was a 2.9% (1/34) fracture malalignment rate when the nail was placed lateral to the center of the joint versus 27.5% (14/51) when placed medial to the center of the joint, with all occurring in valgus. This achieved statistical significance (p=.04). Correlation was highest when measuring the trajectory on mortise view using the talus as reference point. When evaluating the sagittal plane, there were 64 patients that met inclusion criteria with a 48% malalignment rate. Malalignment was greatest when the nail was placed in the anterior quadrant 100% (4/4), versus 50% (22/44) in the anterior middle, and 31.3% (5/16) in the posterior middle quadrant. This achieved statistical significance (p=.05). No nails were placed in the most posterior quadrant. Secondary Cohort: 15 patients met inclusion criteria for distal nail placement. The position of the nail in the coronal plane was
Cohen, Philip R
Subungual melanoma with pigmentation beneath the nail that extends to involve the proximal nail fold is referred to as Hutchinson’s sign. Black or brown subungual discoloration involving the proximal nail fold secondary to other etiologies has been referred to as pseudo-Hutchinson’s sign. Three patients with nail discoloration and concurrent dyschromia of the proximal nail fold are described: a female with a chronic subungual hematoma and pseudo-Hutchinson’s sign, a male with culture-confirmed Pseudomonas aeruginosa (P. aeruginosa) of the nail with green discoloration involving the proximal nail fold, and a male with an acute subungual hematoma with red-purple subungual discoloration affecting the proximal nail fold. PubMed was searched for the following: black, brown, chloronychia, discoloration, dyschromia, green, hematoma, Hutchinson’s sign, nail, nail fold, proximal, pseudo-Hutchinson’s sign, red, subungual melanoma, syndrome. The papers were reviewed and appropriate references evaluated. In conclusion, melanoma-associated black proximal nail fold pigmentation is referred to as Hutchinson’s sign, and non-melanoma-associated black pigmentation has been designated as pseudo-Hutchinson’s sign. Subungual nail plate discoloration extending to involve the proximal nail fold may be black, green, or red-purple in patients with melanocytic and non-melanocytic lesions, bacterial infection (Pseudomonas), and acute subungual hematoma, respectively. Instead of creating a new terminology, we suggest that non-black subungual discoloration (green or red-purple) extending to involve the proximal nail fold be referred to as pseudo pseudo-Hutchinson’s sign. PMID:28090415
Griffin, Lanny V; Harris, Robert M; Zubak, Joseph J
Background Premature failure of either the nail and/or locking screws with unstable fracture patterns may lead to angulation, shortening, malunion, and IM nail migration. Up to thirty percent of all unreamed nail locking screws can break after initial weight bearing is allowed at 8–10 weeks if union has not occurred. The primary problem this presents is hardware removal during revision surgery. The purposes of our study was to evaluate the relative fatigue resistance of distal locking screws and bolts from representative manufacturers of tibial IM nail systems, and develop a relative risk assessment of screws and materials used. Evaluations included quantitative and qualitative measures of the relative performance of these screws. Methods Fatigue tests were conducted to simulate a comminuted fracture that was treated by IM nailing assuming that all load was carried by the screws. Each screw type was tested ten times in a single screw configuration. One screw type was tested an additional ten times in a two-screw parallel configuration. Fatigue tests were performed using a servohydraulic materials testing system and custom fixturing that simulated screws placed in the distal region of an appropriately sized tibial IM nail. Fatigue loads were estimated based on a seventy-five kilogram individual at full weight bearing. The test duration was one million cycles (roughly one year), or screw fracture, whichever occurred first. Failure analysis of a representative sample of titanium alloy and stainless steel screws included scanning electron microscopy (SEM) and quantitative metallography. Results The average fatigue life of a single screw with a diameter of 4.0 mm was 1200 cycles, which would correspond roughly to half a day of full weight bearing. Single screws with a diameter of 4.5 mm or larger have approximately a 50 percent probability of withstanding a week of weight bearing, whereas a single 5.0 mm diameter screw has greater than 90 percent probability of
Griffin, Lanny V; Harris, Robert M; Zubak, Joseph J
Premature failure of either the nail and/or locking screws with unstable fracture patterns may lead to angulation, shortening, malunion, and IM nail migration. Up to thirty percent of all unreamed nail locking screws can break after initial weight bearing is allowed at 8-10 weeks if union has not occurred. The primary problem this presents is hardware removal during revision surgery. The purposes of our study was to evaluate the relative fatigue resistance of distal locking screws and bolts from representative manufacturers of tibial IM nail systems, and develop a relative risk assessment of screws and materials used. Evaluations included quantitative and qualitative measures of the relative performance of these screws. Fatigue tests were conducted to simulate a comminuted fracture that was treated by IM nailing assuming that all load was carried by the screws. Each screw type was tested ten times in a single screw configuration. One screw type was tested an additional ten times in a two-screw parallel configuration. Fatigue tests were performed using a servohydraulic materials testing system and custom fixturing that simulated screws placed in the distal region of an appropriately sized tibial IM nail. Fatigue loads were estimated based on a seventy-five kilogram individual at full weight bearing. The test duration was one million cycles (roughly one year), or screw fracture, whichever occurred first. Failure analysis of a representative sample of titanium alloy and stainless steel screws included scanning electron microscopy (SEM) and quantitative metallography. The average fatigue life of a single screw with a diameter of 4.0 mm was 1200 cycles, which would correspond roughly to half a day of full weight bearing. Single screws with a diameter of 4.5 mm or larger have approximately a 50 percent probability of withstanding a week of weight bearing, whereas a single 5.0 mm diameter screw has greater than 90 percent probability of withstanding more than a week of
Huang, Fu-Ting; Lin, Kai-Cheng; Yang, Shan-Wei; Renn, Jenn-Huei
The purpose of our study was to compare the proximal femoral nail antirotation (PFNA; Synthes, Paoli, Pennsylvania) with a reconstruction nail (Recon; Zimmer, Warsaw, Indiana) in the treatment of comminuted proximal femoral fractures. Between 2003 and 2010, twenty-three consecutive patients with AO/Orthopaedic Trauma Association 31-A3 fractures combined with proximal 32 fractures who had a minimum 18-month follow-up were evaluated retrospectively. There were 10 patients (age range, 18-74 years) in the Recon nail group and 13 patients (age range, 22-90 years) in the PFNA nail group. Patients treated with Recon nails experienced a longer operation time (P=.006) and more blood loss (P=.012) than patients treated with the PFNA nail. On postoperative radiographs, the change in the neck-shaft angle was 8.8° in the Recon nail group and 4.7° in the PFNA nail group (P=.048). The fracture union time averaged 31.8 weeks in the Recon nail group and 21.5 weeks in the PFNA nail group (P=.148). More patients in the Recon nail group underwent major or minor reoperation (P=.038) compared with the PFNA nail group. No implant failure occurred in either group. The functional results were similar in the 2 groups. For the treatment of comminuted proximal femoral fractures, use of either the PFNA and Recon nail is clinically effective. However, the PFNA nail provides a shorter operation time, less blood loss, and better realignment ability and reduces the incidence of reoperation. Therefore, the PFNA nail can be considered a better device than the Recon nail. Copyright 2012, SLACK Incorporated.
Kuhn, Sebastian; Greenfield, Julia; Arand, Charlotte; Jarmolaew, Andrey; Appelmann, Philipp; Mehler, Dorothea; Rommens, Pol M
In factures of the distal tibia with simple articular extension, the optimal surgical treatment remains debatable. In clinical practice, minimally invasive plate osteosynthesis and intramedullary nailing are both routinely performed. Comparative biomechanical studies of different types of osteosynthesis of intraarticular distal tibial fractures are missing due to the lack of an established model. The goal of this study was first to establish a biomechanical model and second to investigate, which are the biomechanical advantages of angle-stable plate osteosynthesis and intramedullary nailing of distal intraarticular tibial fractures. Seven 4(th) generation biomechanical composite tibiae featuring an AO 43-C2 type fracture were implanted with either osteosynthesis technique. After primary lag screw fixation, 4-hole Medial Distal Tibial Plate (MDTP) with triple proximal and quadruple distal screws or intramedullary nailing with double proximal and triple 4.0mm distal interlocking were implanted. The stiffness of the implant-bone constructs and interfragmentary movement were measured under non-destructive axial compression (350 and 600 N) and torsion (1.5 and 3Nm). Destructive axial compression testing was conducted with a maximal load of up to 1,200 N. No overall superior biomechanical results can be proclaimed for either implant type. Intramedullary nailing displays statistically superior results for axial loading in comparison to the MDTP. Torsional loading resulted in non-statistically significant differences for the two-implant types with higher stability in the MDTP group. From a biomechanical view, the load sharing intramedullary nail might be more forgiving and allow for earlier weight bearing in patients with limited compliance.
Manda, Prashanth; Sammeta, Srinivasa M; Repka, Michael A; Murthy, S Narasimha
The main objective of the present study was to investigate the plausibility of iontophoretic delivery of drugs to the nail matrix via proximal nail fold. The in vitro drug transport studies were performed in Franz diffusion cells across folded epidermis, which is used as a model for the proximal nail fold. The amount of drug transported into the receiver compartment following iontophoresis for 3 h at 0.5 mA/cm(2) was 150-fold higher than the control (0.008 ± 0.002 μg/cm(2)). The amount of drug present in the skin after iontophoresis (0.45 ± 0.12 μg/mg) was approximately fivefold higher as compared with that of the control (0.08 ± 0.01 μg/mg). Iontophoresis of terbinafine across the proximal nail fold was assessed using excised cadaver toe model as well. A custom-designed foam-pad-type patch system was used for iontophoresis in cadaver toes. The amount of the drug delivered into the nail matrix following iontophoresis for 3 h was significantly higher than the minimum inhibition concentration of terbinafine. However, on the contrary, passive delivery for about 24 h did not result in any detectable drug levels in the nail matrix. Iontophoresis across the proximal nail fold could be developed as a potential method to target drugs to nail matrix. Copyright © 2012 Wiley Periodicals, Inc.
Aksahin, Ertugrul; Yilmaz, Serdar; Karasoy, Ismail; Duran, Semra; Yuksel, H Yalcin; Dogan, Ozgur; Yildirim, A Ozgur; Bicimoglu, Ali
The aim of the study was to analyse the patellofemoral alignment in the sagittal plane following tibial fracture surgery with intramedullary nailing and its relationship to parapatellar muscle status. The patellofemoral MRI results of 27 patients (15 males and 12 females) treated with locked intramedullary nailing following tibia shaft fracture were reviewed. The mean age of the patients was 41.8 (±15) years. The patella-patellar tendon angle (P-PT) and the distance between the inferior patellar pole and the tibial tubercle (DP-TT) were evaluated for both the operated extremity and the contralateral normal side. MRI assessment of the infrapatellar fat pad, quadriceps, sartorius, gracilis, semi-membranosus muscles and biceps muscles was also carried out. The correlation between the changes in skeletal muscle mass, the volume of the infrapatellar fat pad and the alterations in the DP-TT distances and P-PT angles were analysed. The quadriceps muscle cross-sectional diameter had a mean of 157.2 mm(2) (115.6/319.5) in the operated extremity, and it was 193 mm(2) (77.6/282.2) in the non-operated normal side (p = 0.001). For the Gracilis muscle, the mean was 84.4 mm(2) (19.7/171) at the operated extremity and 75.7 mm(2) (26.9/238.2) on the normal side (p = 0.05). The cross-sectional areas of the semi-membranosus, sartorius and biceps muscles in the operated and non-operated extremity were not noticeably different (n.s). The P-PT angle was 153° (129.7/156.4) in the operated extremity and 145.7° (137.6/163.4) in the non-operated normal extremity (p < 0.05). While DP-TT distance was 11.4 mm (9.4/20.4) in the operated extremity, it was 14.1 mm (7.3/17.1) in the non-operated extremity (p = 0.001). The correlation analyses revealed that the quadriceps hypotrophy negatively correlated (r = -0.4, p = 0.02) with the P-PT angle but positively correlated with the increase in gracilis muscle volume (r = 0.4, p = 0.03). This study revealed that patellofemoral
Silva, Carlos Francisco Bittencourt; Camara, Eduardo Kastrup Bittencourt; Vieira, Luiz Antonio; Adolphsson, Fernando; Rodarte, Rodrigo Ribeiro Pinho
Objective: To radiographically evaluate individuals who underwent opening wedge proximal tibial osteotomy, with the aim of analyzing the proximal tibial slope in the frontal and sagittal planes, and the patellar height. Method: The study included 22 individuals who were operated at the National Traumatology and Orthopedics Institute (INTO) for correction of varus angular tibial deviation using the opening wedge osteotomy (OWO) technique with the Orthofix monolateral external fixator. Patients with OWO whose treatment was completed between January 2000 and December 2006 were analyzed. The measurement technique consisted of using anteroposterior radiographs with loading and lateral views with the operated knees flexed at 30°. Results: There were no statistically significant differences between the pre and postoperative tibial slope and patellar height values in the patients evaluated. Conclusion: Opening wedge proximal tibial osteotomy is a technique that avoids the problems presented by high proximal tibial osteotomy, since it is done without causing changes to the extensor mechanism, ligament imbalance or distortions in the proximal tibia. PMID:27022577
Chen, Yen-Nien; Lee, Pei-Yuan; Chang, Chih-Han; Chang, Chih-Wei; Ho, Yi-Hung; Li, Chun-Ting; Peng, Yao-Te
Elastic stable intramedullary nailing (ESIN) is a treatment strategy for the management of diaphyseal long-bone fractures in adolescents and children, but few studies have investigated the mechanical stability of tibial diaphyseal fractures treated with various degrees of prebending of the elastic nails. Therefore, the aim of this study was to compare the mechanical stability, including the gap deformation and nail dropping, of a tibia fracture with various fracture sites and fixed with various degrees of prebending of the elastic nails by the finite element method. Furthermore, the contribution of end caps to stability was taken into consideration in the simulation. A tibia model was developed with a transverse fracture at the proximal, middle and distal parts of the diaphysis, and fixed with three degrees of prebending of elastic nails, including those equal to, two times and three times the diameter of the intramedullary canal. The outer diameter of the nail used in the computation was 3.5mm, and the fractured tibia was fixed with two elastic double C-type nails. Furthermore, the proximal end of each nail was set to free or being tied to the surrounding bone by a constraint equation to simulate with or without using end caps. The results indicated that using end caps can prevent the fracture gap from collapsing by stopping the ends of the nails from dropping back in all prebending conditions and fracture patterns, and increasing the prebending of the nails to a degree three times the diameter of the canal reduced the gap shortening and the dropping distance of the nail end in those without using end caps under axial compression and bending. Insufficient prebending of the nails and not using end caps caused the gap to collapse and the nail to drop back at the entry point under loading. Using end caps or increasing the prebending of the nails to three times the diameter of the canal is suggested to stop the nail from dropping back and thus produce a more stable
Wegmann, Kilian; Burkhart, Klaus Josef; Buhl, Jörg; Gausepohl, Thomas; Koebke, Jürgen; Müller, Lars Peter
In intramedullary tibial nailing, multi-planar locking makes stabilization of proximal and distal metaphyseal fractures possible. A known complication in intramedullary nailing of the tibia is iatrogenic injury to neuro-vascular structures caused by the insertion of locking screws. As shown in previous studies, the distal positioning of the nail is important, as it determines the course of the locking bolts. The goal of the present study was to display the consequences of posterior nail malpositioning with respect to the safety of the distal medio-lateral locking screws and the available options. Human cadaveric legs were plastinated according to the sequential plastination technique after intramedullary nailing of the tibia and were then cut transversely. The tibial nails were placed centrally or posteriorly. Macroscopic analysis showed a distinct drawback of posterior nail positioning, with diminished options for the placement of the locking screws and thereby a risk of damaging the anterior and posterior neuro-vascular bundles by distal medio-lateral locking screws.
Gaines, Robert J; Rockwood, Jason; Garland, Joshua; Ellingson, Christopher; Demaio, Marlene
The purpose of this study was to determine differences in insertional articular trauma in infrapatellar tibial portal and suprapatellar portal intramedullary tibial nail insertion techniques. A cadaveric study was performed on 10 matched pairs of fresh-frozen adult cadaver lower extremities with intact extensor mechanisms. Two study groups with 10 limbs each were created: left lower limbs were treated with a standard medial parapatellar nailing portal and right lower limbs were treated with a suprapatellar tibial nailing portal. Start points were created under fluoroscopic guidance in anteroposterior and mediolateral planes. A start wire was placed and opening reaming was performed on the specimens using instrumentation specific to the nailing portal. Specimens were then dissected by medial parapatellar arthrotomy, revealing the intra-articular condition of the knee structures. The border of the tibial entry reamer hole was measured to the anterior horns of the menisci, anterior cruciate ligament root, and intermeniscal ligament using a digital caliper accurate to 0.02 mm. The structure was considered damaged if the structure was obviously damaged on visual inspection or if a measurement was less than 1 mm. Impact to intra-articular structures was numerically lower in the suprapatellar group (2/10) compared with the infrapatellar group (4/10), but the difference was not statistically significant between the 2 groups (P=.629). The suprapatellar portal approach to the tibial start point demonstrated a lower overall incidence of damage to intra-articular structures, but no significant statistical difference existed between the 2 treatment groups.
Pullen, W Michael; Erdle, Nicholas J; Crickard, Colin; Smith, Christopher S
Intramedullary tibial fixation is a commonly used and highly successfully treatment in acute fractures, nonunion settings, and correctional procedures. In the setting of a nonunion, removal of a failed implant can add to operative time and surgeon frustration while further compromising bone in an area already at risk for failure. Here we present a technique, using readily accessible equipment, for removing a distal solid tibial nail fragment in a manner that preserves bone.
Yaligod, Vishwanath; Rudrappa, Girish H.; Nagendra, Srinivas; Shivanna, Umesh M.
Background The complications of intramedullary nailing of distal third tibial shaft and metaphyseal fractures have a direct impact on ankle and hind foot function. Methods We retrospectively evaluated 28 patients. Unreamed nail was negotiated across the well reduced fracture till subchondral bone and fixed with 2 to 3 distal locking screws in different planes. Results Fracture union rate was 85%. Three out of 28 patients had malalignment. Mean ankle, hindfoot functional score was 85. Conclusion Complications can be minimized by impacting the unreamed nail till the subchondral bone while maintaining the fracture well reduced and by using multiple distal locking screws in different planes. PMID:24719527
Courtney, P Maxwell; Boniello, Anthony; Donegan, Derek; Ahn, Jaimo; Mehta, Samir
We conducted a study to determine differences in knee pain in patients who underwent either traditional infrapatellar nailing or suprapatellar nailing. From a single institution, we identified patients who had an isolated tibial shaft fracture (Orthopaedic Trauma Association type 42 A-C) surgically fixed with an intramedullary nail between 2009 and 2012. Each patient was contacted by telephone by an investigator blinded to surgical exposure, and the Oxford Knee Score (OKS) questionnaire was administered. Operative time and quality of reduction on postoperative radiographs were compared between the 2 approaches. Twenty-four patients underwent infrapatellar nailing, and 21 patients had a suprapatellar nail placed with approach-specific instrumentation. Mean OKS (maximum, 48 points) was 40.1 for the infrapatellar group and 36.7 for the suprapatellar group (P = .293). Compared with the infrapatellar approach, suprapatellar nailing improved radiographic reduction in the sagittal plane (2.90° vs 4.58°; P = .044) and required less operative fluoroscopy time (81 vs 122 s; P = .003). We found no difference in OKS between the infrapatellar and suprapatellar approaches. Although further study is needed, the suprapatellar entry portal appears to be a safe alternative for tibial nailing with use of appropriate instrumentation.
Bilen, F E; Kocaoglu, M; Eralp, L; Balci, H I
We report the results of using a combination of fixator-assisted nailing with lengthening over an intramedullary nail in patients with tibial deformity and shortening. Between 1997 and 2007, 13 tibiae in nine patients with a mean age of 25.4 years (17 to 34) were treated with a unilateral external fixator for acute correction of deformity, followed by lengthening over an intramedullary nail with a circular external fixator applied at the same operating session. At the end of the distraction period locking screws were inserted through the intramedullary nail and the external fixator was removed. The mean amount of lengthening was 5.9 cm (2 to 8). The mean time of external fixation was 90 days (38 to 265). The mean external fixation index was 15.8 days/cm (8.9 to 33.1) and the mean bone healing index was 38 days/cm (30 to 60). One patient developed an equinus deformity which responded to stretching and bracing. Another developed a drop foot due to a compartment syndrome, which was treated by fasciotomy. It recovered in three months. Two patients required bone grafting for poor callus formation. We conclude that the combination of fixator-assisted nailing with lengthening over an intramedullary nail can reduce the overall external fixation time and prevent fractures and deformity of the regenerated bone.
el Banna, S; Burny, F; Bourgois, R; Donkerwolcke, M; Moulart, F
One of the factors determining the stability of osteosynthesis is the mechanical strength of the bone fragments required for the anchorage of the implant. The aim is to study the driving of a Thornton nail in the proximal epiphysis of a human femur as a way to measure the strength of the trabecular bone and to predict the stability of the implanted system.
Background: There remains a compelling biological rationale for both reamed and unreamed intramedullary nailing for the treatment of tibial shaft fractures. Previous small trials have left the evidence for either approach inconclusive. We compared reamed and unreamed intramedullary nailing with regard to the rates of reoperations and complications in patients with tibial shaft fractures. Methods: We conducted a multicenter, blinded randomized trial of 1319 adults in whom a tibial shaft fracture was treated with either reamed or unreamed intramedullary nailing. Perioperative care was standardized, and reoperations for nonunion before six months were disallowed. The primary composite outcome measured at twelve months postoperatively included bone-grafting, implant exchange, and dynamization in patients with a fracture gap of <1 cm. Infection and fasciotomy were considered as part of the composite outcome, irrespective of the postoperative gap. Results: One thousand two hundred and twenty-six participants (93%) completed one year of follow-up. Of these, 622 patients were randomized to reamed nailing and 604 patients were randomized to unreamed nailing. Among all patients, fifty-seven (4.6%) required implant exchange or bone-grafting because of nonunion. Among all patients, 105 in the reamed nailing group and 114 in the unreamed nailing group experienced a primary outcome event (relative risk, 0.90; 95% confidence interval, 0.71 to 1.15). In patients with closed fractures, forty-five (11%) of 416 in the reamed nailing group and sixty-eight (17%) of 410 in the unreamed nailing group experienced a primary event (relative risk, 0.67; 95% confidence interval, 0.47 to 0.96; p = 0.03). This difference was largely due to differences in dynamization. In patients with open fractures, sixty of 206 in the reamed nailing group and forty-six of 194 in the unreamed nailing group experienced a primary event (relative risk, 1.27; 95% confidence interval, 0.91 to 1.78; p = 0
Bhandari, Mohit; Guyatt, Gordon; Tornetta, Paul; Schemitsch, Emil H; Swiontkowski, Marc; Sanders, David; Walter, Stephen D
There remains a compelling biological rationale for both reamed and unreamed intramedullary nailing for the treatment of tibial shaft fractures. Previous small trials have left the evidence for either approach inconclusive. We compared reamed and unreamed intramedullary nailing with regard to the rates of reoperations and complications in patients with tibial shaft fractures. We conducted a multicenter, blinded randomized trial of 1319 adults in whom a tibial shaft fracture was treated with either reamed or unreamed intramedullary nailing. Perioperative care was standardized, and reoperations for nonunion before six months were disallowed. The primary composite outcome measured at twelve months postoperatively included bone-grafting, implant exchange, and dynamization in patients with a fracture gap of <1 cm. Infection and fasciotomy were considered as part of the composite outcome, irrespective of the postoperative gap. One thousand two hundred and twenty-six participants (93%) completed one year of follow-up. Of these, 622 patients were randomized to reamed nailing and 604 patients were randomized to unreamed nailing. Among all patients, fifty-seven (4.6%) required implant exchange or bone-grafting because of nonunion. Among all patients, 105 in the reamed nailing group and 114 in the unreamed nailing group experienced a primary outcome event (relative risk, 0.90; 95% confidence interval, 0.71 to 1.15). In patients with closed fractures, forty-five (11%) of 416 in the reamed nailing group and sixty-eight (17%) of 410 in the unreamed nailing group experienced a primary event (relative risk, 0.67; 95% confidence interval, 0.47 to 0.96; p = 0.03). This difference was largely due to differences in dynamization. In patients with open fractures, sixty of 206 in the reamed nailing group and forty-six of 194 in the unreamed nailing group experienced a primary event (relative risk, 1.27; 95% confidence interval, 0.91 to 1.78; p = 0.16). The present study demonstrates a
Background: Intramedullary nailing is an effective approach for treatment of diaphyseal tibial fractures. However, infrapatellar intramedullary nailing can easily cause angulation and rotation displacement at the fracture ends and increase risk of postoperative infection. Intramedullary nailing via the suprapatellar approach was proved with good reduction and fixation. We used locked intramedullary nailing for the treatment of tibial fractures via a suprapatellar approach in this study. Materials and Methods: 23 patients undergoing tibial fractures fixation by locked META intramedullary nailing via a suprapatellar approach were enrolled between June 2012 and October 2013. There were 18 males and 5 females. The average age was 35.5 years (range 18-60 years). The intraoperative data including operative time and blood loss and postoperative data consisting of hospital stays, fluoroscopy time, fracture healing time and complications were all recorded. Results: The average operative time, blood loss, fluoroscopy time and hospital stay were 78.2 ± 9.1 min, 90.4 ± 23.4 mL, 38.5 ± 6.5 s and 11 ± 3.4 days respectively. The mean followup period in all the patients was 15.5 months. Callus appeared in the patients at average 8 weeks after surgery. The mean knee and ankle range of motion were significantly improved at the last followup (P < 0.05). The average Hospital for Special Surgery and Olerud–Molander scores was 92 ± 4.3 points and 93.6 ± 3.9 points, respectively. No complications were observed. Conclusion: Locked META intramedullary nail fixation via a suprapatellar approach is safe and effective for patients suffering from tibial fractures and earlier functional recovery. PMID:27293289
Choi, Eun-Seok; Han, Ilkyu; Cho, Hwan Seong; Park, In Woong; Park, Jong Woong
Background Endoprosthetic reconstruction is widely applied for pathological fractures of the proximal humerus; however, functional impairment is usually unsatisfactory. The aims of the current study are to evaluate the reliability of interlocking intramedullary (IM) nailing with cement augmentation as a fixation method in proximal humeral lesions and to assess functional outcomes. Methods We reviewed 32 patients with pathological fractures of the proximal humerus who underwent interlocking IM nailing and cement augmentation. Functional scores and pain relief were assessed as outcomes. Results The mean follow-up period was 14.2 months. The mean Musculoskeletal Tumor Society functional score and Karnofsky performance status scale score were 27.7 and 75.6, respectively. Improvement of pain assessed using the visual analogue scale was 6.2 on average. Thirty-one patients (97%) experienced no pain after surgery. The mean ranges of forward flexion and abduction were 115° and 112.6°, respectively. All patients achieved stability and had no local recurrence without failure of fixation until the last follow-up. Conclusions Proximal interlocking IM nailing with cement augmentation appears to be a reliable treatment option for pathological or impending fractures of the proximal humerus in selected patients with metastatic tumors, even with extensive bone destruction. PMID:27904730
Stinner, Daniel J; Mir, Hassan
Despite poor early results with intramedullary nailing of extra-articular proximal tibia fractures, improvements in surgical technique and implant design modifications have resulted in more acceptable outcomes. However, prevention of the commonly encountered apex anterior and/or valgus deformities remains a challenge when treating these injuries. It is necessary for the surgeon to recognize this and know how to neutralize these forces. Surgeons should be comfortable using a variety of the reduction techniques presented to minimize fracture malalignment.
Plasschaert, V F; Johansson, C G; Micheli, L J
This article describes the use of intramedullary rodding as a treatment for an anterior tibial stress fracture in a patient with high functional demands: a professional ballet dancer. In our patient, a year of conservative treatment and later tibial drilling was unsuccessful. After sustaining a complete fracture at the site of the stress fracture, he was treated with intramedullary rodding and was able to dance 21 weeks after surgery. The fracture went on to complete healing. The role of prophylactic intramedullary nailing in this difficult fracture is discussed.
Zifko, B; Poigenfürst, J; Pezzei, C
Unstable subcapital fractures and dislocation fractures of the humerus can usually be set by closed reduction. Stabilization of these fractures by intramedullary pins is a method which avoids damage to the soft tissues around the shoulder. Since 1985, elastic steel pins with special features have been in use. The last 20 mm of the tip of the pins is angulated at 15 degrees, and the distal end is curved in a special way for the last 20 mm. According to our experience, the results after using this method in the treatment of unstable fractures of the surgical neck (ASIF type A II/2) and dislocation fractures (ASIF type A III/2) are fair to very good. For unstable fractures (ASIF type C I/2) and other dislocation fractures (ASIF type C III/2), the method is only suitable if good reduction is possible. Between the end of February 1985 and the end of December 1990, 101 fractures of the proximal end of the humerus were treated by closed reduction and fixation with intramedullary pins. Following fractures in the anatomical neck, aseptic necrosis of the fragment of the head leads to unfavorable results. In two patients, pseudarthrosis with poor function developed. Disturbance of wound healing, postoperative hematoma, infection, myositis ossificans, or Sudeck's desease have not been observed.
Ludwig, Meryl; Hymes, Robert A; Schulman, Jeff; Pitta, Michael; Ramsey, Lolita
Tibia fracture is the most common type of long bone fracture, and intramedullary nailing is the preferred treatment. In open fractures, a provisional plate is often used to maintain reduction. It is unknown whether this practice increases the risk of infection or other complications. This study retrospectively compared patients who were treated at a level 1 trauma center with intramedullary nailing of an open tibia fracture. Patients who were included: (1) were 18 years or older; (2) were treated between January 1, 2005, and June 30, 2013; (3) had an open fracture of the tibia; and (4) were treated operatively with intramedullary nailing, with or without provisional plate fixation. Patient sex, history of diabetes, history of smoking, mechanism of injury, and side of injury were analyzed. Postoperative complications included infection, delayed union or non-union, compartment syndrome, and death. After the authors controlled for age, Gustilo-Anderson type, and AO/Orthopaedic Trauma Association classification, they found that provisional plate use did not significantly increase the risk of infection (adjusted odds ratio, 1.64; 95% confidence interval, 0.51-5.32; P=.41) or any other complications (adjusted odds ratio, 1.24; 95% confidence interval, 0.46-3.35; P=.67). In the subgroup of patients who had a provisional plate (n=35), removal of the plate did not significantly decrease the risk of infection (adjusted odds ratio, 0.43; 95% confidence interval, 0.07-2.69; P=.36) or other complications (adjusted odds ratio, 0.55; 95% confidence interval, 0.12-2.46; P=.44). In open tibia fractures treated with intramedullary nailing, provisional plate stabilization, a valuable reduction aid, did not increase the risk of infection or other complications. Because of the small subgroup size, however, definitive conclusions cannot be drawn about removal of these provisional plates. [Orthopedics. 2016; 39(5):e931-e936.]. Copyright 2016, SLACK Incorporated.
Kim, Hayoung; Lee, Sang Ki; Kim, Kap Jung; Ahn, Jae Hoon; Choy, Won Sik; Kim, Yong In; Koo, Jea Yun
The aim of this study was to evaluate the efficacy of tibial lengthening using a reamed type intramedullary nail and an Ilizarov external fixator for the treatment of leg length discrepancy or short stature. This retrospective study was performed on 18 tibiae (13 patients) in which attempts were made to reduce complications. We used an Ilizarov external fixator and a nail (10 mm diameter in 17 tibiae and 11 mm in one tibia) in combination. Average limb lengthening was 4.19 cm (range, 2.5-5.5). The mean duration of external fixation was 12.58 days per centimetre gain in length, and the mean consolidation index was 40.53 (range, 35.45-51.85). All distracted segments healed spontaneously without refracture or malalignment. Gradual limb lengthening using a reamed type intramedullary nail and circular external fixation in combination was found to be reliable and effective and reduced external fixation time with fewer complications.
Soni, Ritesh Kumar; Mehta, Surender Mohan; Awasthi, Bhanu; Singh, Janith Lal; Kumar, Amit; Thakur, Lokesh; Tripathy, Sujit Kumar
Background: Distal interlocking screw insertion in intramedullary nailing of long-bone fracture is a challenging task for orthopedic surgeons. It is difficult particularly when the surgeon is in his learning stage or when image intensifier is not available. We describe a radiation-free technique of distal interlocking screw insertion which is easy and practicable. Materials and Methods: In this technique, a same length nail is placed over the skin (outer nail) and through its distal-most screw hole, a 3.2 mm drill bit is inserted to drill the distal locking screw hole of the intramedullary nail (inner nail). With a small skin incision over the distal screw holes, the distal-most screw hole is identified; the bone window overlying the screw hole is widened with an awl and a locking bolt is inserted with a washer under direct visualization. The other distal interlocking screw is simply drilled by matching the other three holes of the outer and inner nails. We have operated 86 patients (39 femoral shaft fracture and 47 tibial shaft fracture) in 1 year where this technique was used. There were 41 open fracture and 45 closed fracture. Results: Within 6 months of follow-up, bony union was achieved in 36 of 39 femur fractures and 45 of 47 tibial fractures. No unwanted complications were observed during the postoperative period and in follow-up. Conclusion: This method of radiation-free distal interlocking screw insertion is simple and can be used in third world country where image intensifier facility is not available. However, surgeons are encouraged to use image intensifier facility where the facility is available. PMID:23066456
Frankle, M; Cordey, J; Sanders, R W; Koval, K; Perren, S M
Femoral shaft fractures with and without bony contact were simulated in cadaver specimens fixed with one of two different types of intramedullary locked nail systems; conventional antegrade nail fixation of the femur with the universal AO femoral nail or retrograde insertion in the femur with the universal tibial nail (a smaller diameter slotted nail) were utilized. Mechanical testing simulated one leg stance, and resultant deformation was measured in bending, torsion, and shortening. In stable fractures, fracture stability was similar to both devices, while in unstable fractures, the larger femoral nail was more stable. Furthermore, the simulation of single leg stance led to a coupled deformation of varus bending, axial shortening, and external rotation, which was dependent on bone geometry.
Xia, Liheng; Zhou, Jian; Zhang, Yongtao; Mei, Gang; Jin, Dan
Controversy exists regarding the clinical outcomes of reamed vs unreamed intramedullary nailing in the treatment of closed tibial fractures. This study assessed the effects of reamed vs unreamed intramedullary nailing for closed tibial fractures. The authors searched PubMed, EMBASE, BIOSIS, and the Cochrane Controlled Trials Register for randomized and quasi-randomized controlled clinical trials from January 1980 to June 2012 comparing reamed with unreamed intramedullary nailing for closed tibial fracture in adults. Primary outcomes were nonunion, delayed union, malunion, secondary procedure, failure of implants, compartment syndrome, infection, and knee pain. Eight randomized and 1 quasi-randomized clinical trials (1229 fractures) were included. No statistically significant differences were found between reamed and unreamed nailing groups in delayed union (P=.20), malunion (P=.28), infection (P=.36), compartment syndrome (P=.36), and knee pain (P=.93). The unreamed group had a higher rate of fracture nonunion than the reamed group (P=.02). The subgroup analysis of implant failures (broken screws vs broken nails) indicated that reamed nailing significantly reduced the risk of screw breakage (P<.001); however, there was no significant difference between reamed and unreamed intramedullary nailing in nail breakage (P=.94). The subgroup analysis of a secondary procedure showed that the reamed intramedullary nailing resulted in significantly lower risks of implant exchange (P=.01) and dynamization (P=.04); however, there was no significant difference in bone grafting rate (P=.73). Evidence comparing reamed with unreamed intramedullary nailing for closed tibial fractures indicates that reamed intramedullary nailing may lead to significantly lower risks of nonunion, screw failure, implant exchange, and dynamization without increasing operative complications.
Amarathunga, J P; Schuetz, M A; Yarlagadda, K V D; Schmutz, B
Intramedullary nailing is the standard fixation method for displaced diaphyseal fractures of tibia. Selection of the correct nail insertion point is important for axial alignment of bone fragments and to avoid iatrogenic fractures. However, the standard entry point (SEP) may not always optimise the bone-nail fit due to geometric variations of bones. This study aimed to investigate the optimal entry for a given bone-nail pair using the fit quantification software tool previously developed by the authors. The misfit was quantified for 20 bones with two nail designs (ETN and ETN-Proximal Bend) related to the SEP and 5 entry points which were 5 mm and 10 mm away from the SEP. The SEP was the optimal entry point for 50% of the bones used. For the remaining bones, the optimal entry point was located 5 mm away from the SEP, which improved the overall fit by 40% on average. However, entry points 10 mm away from the SEP doubled the misfit. The optimised bone-nail fit can be achieved through the SEP and within the range of a 5 mm radius, except posteriorly. The study results suggest that the optimal entry point should be selected by considering the fit during insertion and not only at the final position.
Liu, Lin; Xu, Xian; Li, Xu; Wu, Wei; Cai, Junfeng; Lu, Qingyou
BACKGROUND This prospective study aimed to compare clinical effects of intramedullary nailing guided by digital and conventional technologies in treatment of tibial fractures. MATERIAL AND METHODS Thirty-two patients (mean age 43 years, 18 males and 14 females) who were treated for tibial fractures from October 2010 to October 2012 were enrolled. They were sequentially randomized to receive intramedullary nailing guided by either digital technology (digital group, n=16) or conventional technology (conventional group, n=16). The operation time, fluoroscopy times, fracture healing time, distance between the actual and planned insertion point, postoperative lower limb alignment, and functional recovery were recorded for all patients. RESULTS The mean operation time in the digital group was 43.1±6.2 min compared with 48.7±8.3 min for the conventional technology (P=0.039). The fluoroscopy times and distance between the actual and planned insertion point were significantly lower in the digital group than in the conventional group (both P<0.001). The accuracy rate of the insertion point was 99.12% by digital technology. No difference was found in fracture healing time and good postoperative lower limb alignment between the digital and conventional groups (P=0.083 and P=0.310), as well as the effective rate (100% vs. 87.50%, P=0.144). CONCLUSIONS Intramedullary nailing guided by digital technology has many advantages in treatment of tibial fractures compared to conventional technology, including shorter operation time, reduced fluoroscopy times, and decreased distance between the actual and planned insertion point of the intramedullary nail.
Beytemür, Ozan; Albay, Cem; Adanır, Oktay; Yüksel, Serdar; Güleç, Mehmet Akif
This study aims to evaluate the functional and radiographic results and treatment complications of AO/OTA (Arbeitsgemeinschaft fur Osteosynthesefragen/Orthopaedic Trauma Association) type 43C1 and C2 fractures treated with intramedullary nailing. We retrospectively evaluated 35 AO/OTA type 43C1 and C2 patients (26 males, 9 females; mean age 39.8±16.9 years; range 19 to 82 years) treated with intramedullary nailing. Two interfragmentary screws out of nail were applied in 10 patients (29%), while one interfragmentary screw out of nail was applied in 17 patients (49%). Intramedullary nailing was applied in eight patients (23%) without external screws. Fracture union, union time, alignment problems, and complications were evaluated. Clinical evaluation of patients was conducted using the Olerud and Molander score and by measuring the ankle joint range of motion. Union was achieved in all 35 patients. Mean union time was 16.5±2.8 weeks (range 12 to 24 weeks) and mean Olerud and Molander score was 88±8.24. Varus deformity was detected in one patient, valgus deformity was detected in two patients, and rotation deformity was detected in one patient. Superficial infection was detected in three patients (9%). Deep infection was not detected in any patient. Intramedullary nailing is not contraindicated for simple intra-articular distal tibial fractures. In these fractures, intramedullary nailing performed in accordance with its technique, with an additional percutaneous screw if necessary, is a successful treatment option with high fracture union rates, high functional results, and low complication rates.
Bauer, Jennifer M; Bible, Jesse E; Mir, Hassan R
We conducted a study to compare postoperative infection and nonunion rates in tibial intramedullary nails (IMNs) placed through either uninjured knees or traumatic knee arthrotomies (KAs). We reviewed all adult tibial diaphyseal fractures (n = 1378) treated with an IMN between 1998 and 2010. Fourteen of these nails were placed through a traumatic KA. Each patient in the study group was assigned 4 separate matched controls for comparison. Controls were matched on age, sex, diabetes, smoking, and fracture classification (closed or open with Gustilo-Anderson). There were no postoperative infections (knee or fracture site) in the traumatic KA group and 2 (3.5%) in the control group (P = .473). One nonunion (7.1%) was noted in the traumatic KA group, and 9 (16%) were noted in the control group (P = .6694). To our knowledge, this is the first study to report outcomes of placing tibial IMNs through traumatic KAs. In our sample, the practice presented no increased risk either for infection (at the knee or the fracture site) or for nonunion with appropriate surgical debridement.
Hurwitz, D E; Sumner, D R; Andriacchi, T P; Sugar, D A
This study tested the validity of the prediction of dynamic knee loads based on gait measurements. The relationship between the predicted loads at the knee and the distribution of bone between the medial and lateral sides of the tibia was examined. The motion and external forces and moments at the knee were measured during gait and a statically determinate muscle model was used to predict the corresponding forces on the medial and lateral tibial plateaus. In particular, the relationship between the knee adduction moment during gait and the ratio or distribution of medial to lateral tibial bone mineral content was studied. Bone mineral content was measured with dual energy X-ray absorptiometry in four regions, two proximal regions 20 mm in height, one medial and one lateral and two distal regions 20 mm in height, one medial and one lateral. The best single predictor of the medial lateral ratio of proximal bone mineral content (bone distribution) was the adduction moment (R2=0.31, p=0.003). Adding weight (negative coefficient. p=0.0004) and the ratio of the average predicted peak force on the medial plateau to the predicted peak force on the lateral plateau (positive coefficient, p=0.0033) to the regression model significantly increased the ability to predict the proximal medial lateral bone distribution (R2=0.72, p=0.0001). Distally neither the subject characteristics nor the gait moments and predicted forces were significant predictors of the bone distribution. The lack of a correlation distally may be reflective of the forces being more evenly distributed further from the tibial plateau. While it has long been suggested that the adduction moment is the primary determinate of the distribution of load between the medial and lateral plateaus, this is the first evidence of its relationship to the underlying bone distribution.
Cerqueira, Italo Scanavini; Petersen, Pedro Araujo; Júnior, Rames Mattar; Silva, Jorge dos Santos; Reis, Paulo; Gaiarsa, Guilherme Pelosini; Morandi, Massimo
Objective: Intramedullary nails are the gold standard for treating tibial shaft fractures. Knee pain is a frequent complication after the procedure. Alternative routes such as the suprapatellar approach for nail insertion are seen as an option for avoiding late postoperative knee pain. The question is whether this approach might give rise to any injury to intra-articular structures of the knee. Methods: This study analyzed the suprapatellar approach and the risk to adjacent structures by reproducing it in 10 knees of five cadavers. Results: This approach was seen to make it easy to locate the entry point, with lesions only occurring in the Hoffa fat. In three of our cases, there were lesions of the chondral surface, which is an obstacle that is difficult to overcome. Conclusion: There is a need to develop specific material to minimize injury to intra-articular structures when using this route. PMID:27042617
Background Currently, antegrade intramedullary nailing and minimally invasive plate osteosynthesis (MIPO) represent the main surgical alternatives in distal tibial fractures. However, neither choice is optimal for all bony and soft tissue injuries. The Retrograde Tibial Nail (RTN) is a small-caliber prototype implant, which is introduced through a 2-cm-long incision at the tip of the medial malleolus with stab incisions sufficient for interlocking. During this project, we investigated the feasibility of retrograde tibial nailing in a cadaver model and conducted biomechanical testing. Methods Anatomical implantations of the RTN were carried out in AO/OTA 43 A1-3 fracture types in three cadaveric lower limbs. Biomechanical testing was conducted in an AO/OTA 43 A3 fracture model for extra-axial compression, torsion, and destructive extra-axial compression. Sixteen composite tibiae were used to compare the RTN against an angle-stable plate osteosynthesis (Medial Distal Tibial Plate, Synthes®). Statistical analysis was performed by Student's t test. Results Retrograde intramedullary nailing is feasible in simple fracture types by closed manual reduction and percutaneous reduction forceps, while in highly comminuted fractures, the use of a large distractor can aid the reduction. Biomechanical testing shows a statistically superior stability (p < 0.001) of the RTN during non-destructive axial loading and torsion. Destructive extra-axial compression testing resulted in failure of all plate constructs, while all RTN specimens survived the maximal load of 1,200 N. Conclusions The prototype retrograde tibial nail meets the requirements of maximum soft tissue protection by a minimally invasive surgical approach with the ability of secure fracture fixation by multiple locking options. Retrograde tibial nailing with the RTN is a promising concept in the treatment of distal tibia fractures. PMID:24886667
offset from the top of this particular nail to its long axis. Key Words: lateral entry, trochanteric nail , intramedullary nailing , femur, complication...trochanteric intramedullary femoral nailing . J Orthop Trauma. 2005;19:681–686. 8. McConnell T, Tornetta P III, Benson E, et al. Gluteus medius tendon injury...Germany: Stryker Trauma; 2006: 191–199. 11. Gerhard Küntscher. Practice of Intramedullary Nailing . Translated by Herman Rinne. Springfield, IL: Thomas
Lu, Yan; Nemke, Brett; Lorang, Douglas M; Trip, Roel; Kobayashi, Hirohito; Markel, Mark D
To compare bone healing of tibial osteotomy repaired with Nitinol wire braid and hardened steel rods (Braid system) and polymethylmethacrylate bone cement with an interlocking intramedullary (IM) nail fixation in an ovine model. In vitro and in vivo experimental study. Adult female sheep (n=22). Using sheep tibia, a middiaphyseal transverse osteotomy was performed in the right tibia, which were then randomly assigned to the Braid system group or IM nail group (n=5). The left tibia were used as controls. The torsional properties of tibial constructs were compared. The study was repeated in vivo in 12 sheep and mechanical properties and bone healing were evaluated at 12 weeks. In vitro, there was no significant difference in torsional stiffness between the groups. In vivo, operative time for the Braid system group was significantly shorter than the IM nail group. At 12 weeks, there were no significant differences in maximum torque and torsional stiffness between IM nail and Braid system groups nor were there significant radiographic or histologic differences between the groups. The Braid system might decrease operative time for repair of transverse middiaphyseal tibial fractures and result in similar bone healing at 12 weeks after surgery compared with an interlocking IM nail repair. A Nitinol Braid system may be a treatment option for transverse midshaft tibial fractures.
Collinge, Cory A; Beltran, Michael J; Dollahite, Henry A; Huber, Florian G
The reduction of tibial shaft fractures during intramedullary nailing is important if limb alignment is to be restored and successful clinical outcomes are expected. We have used a percutaneously applied (or open) clamp or clamps to achieve and maintain reduction during nailing of all amendable tibial shaft fractures. In this article, we describe the technique and preliminary results comparing closed, simple spiral and oblique tibial shaft fractures (OTA 42-A1 and A2) managed with percutaneous clamp-assisted nailing (CAN) versus nailing using manual reduction (MRN) held by the surgical team. In the MRN group, there were an increased fracture gap (P = 0.04) and trends toward malalignment (P = 0.07) and healing time (P = 0.06) compared with the CAN group. There were also trends in clinical; no wound complications occurred in either group. We have found that percutaneous CAN of closed, simple spiral and oblique tibial shaft fractures seems safe and allows for early predictable union with reproducible alignment compared with nailing using MRN.
Ozkan, Korhan; Türkmen, İsmail; Sahin, Adem; Yildiz, Yavuz; Erturk, Selim; Soylemez, Mehmet Salih
Background: The incidence of fractures in the trochanteric area has risen with the increasing numbers of elderly people with osteoporosis. Although dynamic hip screw fixation is the gold standard for the treatment of stable intertrochanteric femur fractures, treatment of unstable intertrochanteric femur fractures still remains controversial. Intramedullary devices such as Gamma nail or proximal femoral nail and proximal anatomic femur plates are in use for the treatment of intertrochanteric femur fractures. There are still many investigations to find the optimal implant to treat these fractures with minimum complications. For this reason, we aimed to perform a biomechanical comparison of the proximal femoral nail and the locking proximal anatomic femoral plate in the treatment of unstable intertrochanteric fractures. Materials and Methods: Twenty synthetic, third generation human femur models, obtained for this purpose, were divided into two groups of 10 bones each. Femurs were provided as a standard representation of AO/Orthopedic Trauma Associationtype 31-A2 unstable fractures. Two types of implantations were inserted: the proximal femoral intramedullary nail in the first group and the locking anatomic femoral plate in the second group. Axial load was applied to the fracture models through the femoral head using a material testing machine, and the biomechanical properties of the implant types were compared. Result: Nail and plate models were locked distally at the same level. Axial steady load with a 5 mm/m velocity was applied through the mechanical axis of femur bone models. Axial loading in the proximal femoral intramedullary nail group was 1.78-fold greater compared to the plate group. All bones that had the plate applied were fractured in the portion containing the distal locking screw. Conclusion: The proximal femoral intramedullary nail provides more stability and allows for earlier weight bearing than the locking plate when used for the treatment of
Abdelgawad, Amr A
Infantile Blount's disease is a condition that causes genu varum and internal tibial torsion. Treatment options include observation, orthotics, corrective osteotomy, elevation of the medial tibial plateau, resection of a physeal bar, lateral hemi-epiphysiodesis, and guided growth of the proximal tibial physis. Each of these treatment options has its disadvantages. Treating the coronal deformity alone (genu varum) will result in persistence of the internal tibial torsion (the axial deformity). In this report, we describe the combination of lateral growth modulation and distal tibial external rotation osteotomy to correct all the elements of the disease. This has not been described before for treatment of Blount's disease. Both coronal and axial deformities were corrected in this patient. We propose this combination (rather than the lateral growth modulation alone) as the method of treatment for early stages of Blount's disease as it corrects both elements of the disease and in the same time avoids the complications of proximal tibial osteotomy.
Kuhn, Kevin M; Cannada, Lisa K; Watson, J Tracy; Ali, Ashley; Boudreau, John A; Mir, Hassan R; Bauer, Jennifer M; Mullis, Brian; Hymes, Robert; Genova, Renee; Tucker, Michael; Schlatter, Daniel
There are no data-supported recommendations on how proximal is too proximal for retrograde nailing (RGN). At six level 1 trauma centers, patients with femur fractures within the proximal one-third of the femur treated with RGN were included. This article describes a proximal segment capture ratio (PSCR) and nail segment capture ratio to evaluate RGN of proximal fractures. The study included 107 patients. The average follow-up was 44 weeks. There were two nonunions and three malunions. There was no significant difference between PSCR of 0.3 or less and need for secondary procedures or time to full weight bearing (p>.05). In this study, a smaller (< 0.3) PSCR was not associated with an increased number of complications. A higher Orthopaedic Trauma Association classification was predictive of malunion and increased time to union. These data demonstrate that retrograde nailing is safe and effective for the treatment of supraisthmal femur fractures.
Kundu, Zile Singh; Gogna, Paritosh; Gupta, Vinay; Kamboj, Pradeep; Singla, Rohit; Sangwan, Sukhbir Singh
Limb salvage surgery for malignant tumours of proximal humerus is an operative challenge, where the surgeon has to preserve elbow and hand functions and retain shoulder stability with as much function as possible. We treated 14 consecutive patients with primary malignant or isolated metastasis of proximal humerus with surgical resection and reconstruction by nail cement spacer. There were 8 females and 6 males, with a mean age of 28.92 years (range 16-51 years) and a mean follow-up of 30.14 months (range 12-52 months). The diagnosis was osteosarcoma in 8 patients, chondrosarcoma in 4 patients and metastasis from thyroid and breast carcinoma in 1 patient each. One of our patients had radial nerve neuropraxia, 1 developed inferior subluxation and 3 developed distant metastasis. Two patients died of disease and one developed local recurrence leading to forequarter amputation, leaving a total of 11 patients with functional extremities for assessment at the time of final follow-up which was done using the Musculoskeletal Tumour Society (MSTS) score. Though we were able to preserve the elbow, wrist and hand functions in all patients, the abductor mechanism, deltoid muscle and axillary nerve were not salvageable in any of cases. The mean MSTS score at the time of final follow-up was 19.09. Thus, proximal humeral reconstruction using nail cement spacer is a technical simple, cost-effective and reproducible procedure which makes it a reliable option in subset of patients where the functions around the shoulder cannot be preserved despite costlier prosthesis.
Gadegone, Wasudeo M.; Shivashankar, Bhaskaran; Lokhande, Vijayanad; Salphale, Yogesh
Introduction: Biomechanically proximal femoral nail (PFN) is a better choice of implant, still it is associated with screw breakage, cut out of screw through femoral head, Z effect, reverse Z effect, and lateral migration of screws. The purpose of this study is to evaluate the results of augmented PFN in terms of prevention of postoperative complications and failure rates in unstable trochanteric fractures. Material and methods: We carried out a prospective study of 82 cases with unstable trochanteric femoral fractures from April 2010 to December 2015. Forty-two females and 40 males in the age group between 58 and 81 years were included in this study. There were 45 cases of AO 31 A2 (2.2, 2.3) and 37 cases of AO 31 A3 (3.1, 3.2, 3.3). Fractures were fixed by PFN with augmentation by an additional screw from trochanter to inferior quadrant of femoral head or cerclage wire to strengthen the lateral trochanteric wall. Results: The bone healing is observed in all the cases in the mean period of 14.2 weeks. Nine patients developed complications, including lateral migration of neck screws (n = 5), Z effect (n = 1), infection (n = 2), and breakage of distal interlocking bolt in one case. Removal of screws was required in five cases. Patients were followed up for a mean of 8.4 months. At the end of follow-up the Salvati and Wilson hip function was 32 (out of 40) in 88% of patients. Conclusion: The stabilization of lateral trochanteric wall with additional screw or cerclage wire increases the stability of construct. PMID:28186871
Niikura, Takahiro; Lee, Sang Yang; Matsumoto, Tomoyuki; Fukui, Tomoaki; Kawakami, Yohei; Akisue, Toshihiro; Kuroda, Ryosuke; Kurosaka, Masahiro
This article describes a case of backout of the helical blade, a rare complication of proximal femoral nail antirotation. A 31-year-old man had sustained a trochanteric fracture of his right femur. Fracture fixation using proximal femoral nail antirotation and autologous bone grafting 7 months later were performed at another hospital. However, bony union was not obtained, and the patient's pain and limp persisted. Therefore, he presented to the current authors. A radiograph taken at presentation revealed backout of the helical blade and fracture nonunion. A radiograph taken 1 month later showed a more advanced backout of the helical blade. The authors performed exchange nailing supplemented with transplantation of peripheral blood CD34-positive cells and autologous bone grafting. The proximal femoral nail antirotation was revised to a long gamma 3 nail, and a U-lag screw was used to obtain better stability. The postoperative course was uneventful. The patient regained ambulation without pain or support at 12 weeks postoperatively. Radiographic bony union was completed 9 months postoperatively. At 1-year follow-up, he could run and stand on the previously injured leg and had returned to work. Backout of the helical blade should be considered as a possible complication of proximal femoral nail antirotation. Incomplete fixation of the helical blade is the possible reason for backout. The use of a helical blade in young patients may cause difficulty in insertion and result in incomplete fixation.
Tejwani, Nirmal C; Polonet, David; Wolinsky, Philip R
Management of tibia fractures by internal fixation, particularly intramedullary nails, has become the standard for diaphyseal fractures. However, for metaphyseal fractures or those at the metaphyseal-diaphyseal junction, the choice of fixation device and technique is controversial. For distal tibia fractures, nailing and plating techniques may be used, the primary goal for each being to achieve acceptable alignment with minimal complications. Different techniques for reduction of these fractures are available and can be applied with either fixation device. Overall outcomes appear to be nearly equivalent, with minor differences in complications. Proximal tibia fractures can be fixed using nailing, which is associated with deformity of the proximal short segment. A newer technique--suprapatellar nailing--may minimize these problems, and use of this method has been increasing in trauma centers. However, most data are still largely based on case series.
Tejwani, Nirmal; Polonet, David; Wolinsky, Philip R
Management of tibia fractures by internal fixation, particularly intramedullary nails, has become the standard for diaphyseal fractures. However, for metaphyseal fractures or those at the metaphyseal-diaphyseal junction, choice of fixation device and technique is controversial. For distal tibia fractures, nailing and plating techniques may be used, the primary goal of each being to achieve acceptable alignment with minimal complications. Different techniques for reduction of these fractures are available and can be applied with either fixation device. Overall outcomes appear to be nearly equivalent, with minor differences in complications. Proximal tibia fractures can be fixed using nailing, which is associated with deformity of the proximal short segment. A newer technique-suprapatellar nailing-may minimize these problems, and use of this method has been increasing in trauma centers. However, most of the data are still largely based on case series.
Yasuda, Tomohiro; Obara, Shu; Hayashi, Junji; Arai, Masayuki; Sato, Kaoru
Intramedullary nail fixation is a common treatment for tibial-shaft fractures, and it offers a better functional prognosis than other conservative treatments. Currently, the primary approach employed during intramedullary nail insertion is the semiextended position is the suprapatellar approach, which involves a vertical incision of the quadriceps tendon Damage to the patellofemoral joint cartilage has been highlighted as a drawback associated with this approach. To avoid this issue, we perform surgery using the patellar eversion technique and a soft sleeve. This method allows the articular surface to be monitored during intramedullary nail insertion. We arthroscopically assessed the effect of this technique on patellofemoral joint cartilage. The patellar eversion technique allows a direct view and protection of the patellofemoral joint without affecting the patella. Thus, damage to the patellofemoral joint cartilage can be avoided.
Shen, Kaiying; Cai, Haiqing; Wang, Zhigang; Xu, Yunlan
Abstract Elastic stable intramedullary nailing (ESIN) has became a well-accepted method of osteosynthesis of diaphyseal fractures in the skeletally immature patient for many advantages, the purpose of this study is to evaluate the preliminary results of this minimally invasive treatment for severely displaced distal tibial diaphyseal metaphyseal junction (DTDMJ) fractures. This study was carried out over a 6-year period. Twenty-one severely displaced DTDMJ fractures treated using ESIN were evaluated clinically and radiographically. Complications were assessed: the patients were evaluated with regard to nonunion, malunion, infection, growth arrest, leg length discrepancy, implant irritation, and joint function. Mean age at the time of surgery was 7.8 years (range between 5.3 and 14.8 years), mean body weight 34.1 kg, all fractures were transverse or mild oblique type, including 3 open fractures, 5 multifragmented fractures, and 4 fractures associated with polytrauma; 6 cases were treated with antegrade ESIN of tibia while 15 cases need combined retrograde fibula and antegrade tibia fixation treatments. Follow-ups were ranging from 11 to 36 months, 19 fractures showed both clinical and radiographic evidence of healing within 5 months; all cases had full range motion of knee and ankle with symmetrical foot progress angle. Nail removal was at a mean 7.1 months, at final follow-up, no growth arrest or disturbances occurred. Five patients had complications; leg length discrepancy had decreased yet affected 2 patients, 2 cases showed delayed union, and 1 case developed restricted dorsal extension at the metatarsophalangeal joint of the hallux. ESIN is the treatment of choice for pediatric severely displaced DTDMJ fractures that cannot be reduced by closed reduction or ones that cannot be casted. The advantages include faster fracture healing, excellent functional and cosmetic results, safe and reliable surgical technique, and lower severe complication rate. PMID
Dong, Yansheng; Wang, Yongqing; Dong, Limin; Jia, Peng; Lu, Fengcheng
The nail with absorbable sheath (AS nail) is designed to reduce the stress shielding effect of internal fixation with interlocking intramedullary nail. In order to verify its feasibility, two types of the finite element models of internal fixation of tibia with the AS nail and the common metal nail (CM nail) are established using the Softwares of Mimics, Geomagic, SolidWorks and ANSYS according to the CT scanning data of tibia. The result of the finite element analysis shows that the AS nail has great advantages compared with the CM nail in reducing the stress shielding effect in different periods of fracture healing. The conclusion is that the AS nail can realize the static fixation to the dynamic fixation from the early to the later automatically to shorten the time of fracture healing, which also provides a new technique to the interlocking intramedullary nail.
Euler, Simon A; Petri, Maximilian; Venderley, Melanie B; Dornan, Grant J; Schmoelz, Werner; Turnbull, Travis Lee; Plecko, Michael; Kralinger, Franz S; Millett, Peter J
Varus failure is one of the most common failure modes following surgical treatment of proximal humeral fractures. Straight antegrade nails (SAN) theoretically provide increased stability by anchoring to the densest zone of the proximal humerus (subchondral zone) with the end of the nail. The aim of this study was to biomechanically investigate the characteristics of this "proximal anchoring point" (PAP). We hypothesized that the PAP would improve stability compared to the same construct without the PAP. Straight antegrade humeral nailing was performed in 20 matched pairs of human cadaveric humeri for a simulated unstable two-part fracture. Biomechanical testing, with stepwise increasing cyclic axial loading (50-N increments each 100 cycles) at an angle of 20° abduction revealed significantly higher median loads to failure for SAN constructs with the PAP (median, 450 N; range, 200-1.000 N) compared to those without the PAP (median, 325 N; range, 100-500 N; p = 0.009). SAN constructs with press-fit proximal extensions (endcaps) showed similar median loads to failure (median, 400 N; range, 200-650 N), when compared to the undersized, commercially available SAN endcaps (median, 450 N; range, 200-600 N; p = 0.240). The PAP provided significantly increased stability in SAN constructs compared to the same setup without this additional proximal anchoring point. Varus-displacing forces to the humeral head were superiorly reduced in this setting. This study provides biomechanical evidence for the "proximal anchoring point's" rationale. Straight antegrade humeral nailing may be beneficial for patients undergoing surgical treatment for unstable proximal humeral fractures to decrease secondary varus displacement and thus potentially reduce revision rates.
Saxena, Vishal; Anari, Jason B; Ruutiainen, Alexander T; Voleti, Pramod B; Stephenson, Jason W; Lee, Gwo-Chin
Restoration of normal anatomy and proper ligament balance are theoretical prerequisites for reproducing physiological kinematics with bicruciate-retaining total knee arthroplasty (TKA). The purpose of this study was to use a 3D MRI technique to evaluate the topography of the proximal tibia and outline considerations in tibial component design for bicruciate-retaining TKA. We identified 100 consecutive patients (50 males and 50 females) between ages 20 and 40 years with knee MRIs without arthritis, dysplasia, ACL tears, or prior knee surgery. A novel 3D MRI protocol coordinating axial, coronal, and sagittal images was used to measure: 1) medial and lateral posterior tibial slopes; 2) medial and lateral coronal slopes; and 3) distance from the anterior tibia to the ACL footprint. There was no overall difference in medial and lateral posterior tibial slopes (5.5° (95% CI 5.0 to 6.0°) vs. 5.4° (95% CI 4.8 to 6.0°), respectively (p=0.80)), but 41 patients had side-to-side differences greater than 3°. The medial coronal slope was greater than the lateral coronal slope (4.6° (95% CI 4.0 to 5.1°) vs. 3.3° (95% CI 2.9 to 3.7°), respectively (p<0.0001)). Females had less clearance between the anterior tibia and ACL footprint than males (10.8mm (95% CI 10.4 to 11.2mm) vs. 13.0mm (95% CI 12.5 to 13.5mm), respectively (p<0.0001)). Due to highly variable proximal tibial topography, a monoblock bicruciate-retaining tibial baseplate may not reproduce normal anatomy in all patients. Level IV - Anatomic research study. Copyright © 2015 Elsevier B.V. All rights reserved.
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Chen, Daoyun; Chen, Jianmin; Liu, Fanggang; Jiang, Yao
The sequelae of poliomyelitis are the common causes of leg discrepancy. Tibial lengthening is an effective way to solve this problem but it is associated with a high rate of complications. In this study, we combined the use of humeral nail and external fixator in tibial lengthening with the purpose of reducing lengthening complications. Compared with the cases lengthened by a single-plane external fixator alone, this combined strategy was found to be beneficial in maintaining the tibial alignment. Therefore, it can be recommended as a good technique for tibial lengthening in patients with sequelae of poliomyelitis.
Keating, J F; O'Brien, P J; Blachut, P A; Meek, R N; Broekhuyse, H M
Ninety-one patients who had ninety-four open fractures of the tibial shaft were randomized into two treatment groups. Fifty fractures (nine type-I, eighteen type-II, sixteen type-IIIA, and seven type-IIIB fractures, according to the classification of Gustilo et al.) were treated with nailing after reaming, and forty-four fractures (five type-I, sixteen type-II, nineteen type-IIIA, and four type-IIIB fractures) were treated with nailing without reaming. The average diameter of the nail was 11.5 millimeters (range, nine to fourteen millimeters) in the group treated with reaming and 9.2 millimeters (range, eight to ten millimeters) in the group treated without reaming. Follow-up information was adequate for forty-five patients (forty-seven fractures) who had been managed with reaming and forty patients (forty-one fractures) who had been managed without reaming. No clinically important differences were found between the two groups with regard to the technical aspects of the procedure or the rate of early postoperative complications. The average time to union was thirty weeks (range, thirteen to seventy-two weeks) in the group treated with reaming and twenty-nine weeks (range, thirteen to fifty weeks) in the group treated without reaming. Four (9 per cent) of the fractures treated with reaming and five (12 per cent) of the fractures treated without reaming did not unite (p = 0.73). There were two infections in the group treated with reaming and one in the group treated without reaming. Significantly more screws broke in the group treated without reaming (twelve; 29 per cent) than in the group treated with reaming (four; 9 per cent) (p = 0.014). There was no difference between the two groups with regard to the frequency of broken nails (two nails that had been inserted after reaming broke, compared with one that had been inserted without reaming). The functional outcome, in terms of pain in the knee, range of motion, return to work, and recreational activity, did not
Background Fat embolism syndrome is a potentially fatal complication of long bone fractures. It is usually seen in the context of polytrauma or a femoral fracture. There are few reports of fat embolism syndrome occurring after isolated long bone fractures other than those of the femur. Case presentation We describe a case of fat embolism syndrome in a 33-year-old Caucasian man. He was being seen for an isolated Gustilo’s grade II open tibial fracture. He was deemed clinically stable, so we proceeded to treat the fracture with intramedullary reamed nailing. He developed fat embolism syndrome intraoperatively and was treated successfully. Conclusion This case caused us to question the use of injury severity scoring for isolated long bone fractures. It suggests that parameters that have been described in the literature other than that the patient is apparently clinically stable should be used to establish the best time for nailing a long bone fracture, thereby improving patient safety. PMID:24731759
Aparicio, Gustavo; Soler, Isabel; López-Durán, Luis
Fat embolism syndrome is a potentially fatal complication of long bone fractures. It is usually seen in the context of polytrauma or a femoral fracture. There are few reports of fat embolism syndrome occurring after isolated long bone fractures other than those of the femur. We describe a case of fat embolism syndrome in a 33-year-old Caucasian man. He was being seen for an isolated Gustilo's grade II open tibial fracture. He was deemed clinically stable, so we proceeded to treat the fracture with intramedullary reamed nailing. He developed fat embolism syndrome intraoperatively and was treated successfully. This case caused us to question the use of injury severity scoring for isolated long bone fractures. It suggests that parameters that have been described in the literature other than that the patient is apparently clinically stable should be used to establish the best time for nailing a long bone fracture, thereby improving patient safety.
Ramasubbu, Rohan A; Ramasubbu, Benjamin M
Background: Management of open tibial fractures is well documented in adults, with existing protocols outlining detailed treatment strategies. No clear guidelines exist for children. Surgical stabilization of tibial fractures in the pediatric population requires implants that do not disrupt the open epiphyses (growth plate). Both elastic stable intramedullary nails and external fixation can be used. The objective of this study was to identify the optimal method of surgical stabilization in the treatment of open tibial fractures in children. Materials and Methods: MEDLINE and Embase were searched from their inception to March 2014 using the following advanced search terms (Key words): “open tibia fracture,” “fracture fixation,” “external fixation,” “intramedullary,” and “bone nail.” Only studies in English and pertaining to children with open fractures treated with elastic stable intramedullary nails or external fixation between 1994 and 2014 were included. Twelve clinical studies were critically appraised. Results: Due to a paucity in the literature coupled with a nonsystematic presentation of results, it proved to be very difficult in extracting relevant results from the studies. This was further added by a variation in outcome measures. Consequently, the results we obtained were difficult to draw conclusions from. Conclusion: There is no conclusive evidence or best practice guidelines for their management. Thus, as is highlighted in this study, more research is needed to determine the optimum treatment strategy for this common pediatric injury. The existing literature is of poor quality; consisting mainly of retrospective reviews of patients’ medical records, charts, and radiographs. Carefully designed, high-quality prospective cohort studies utilizing a nationalized multi-hospital approach are needed to improve understanding before protocols and guidelines can be developed and implemented. PMID:27746486
Gong, He; Wang, Lizhen; Zheng, Dong; Fan, Yubo
Proximal femoral nail antirotation (PFNA) device is an intramedullary nail system designing for the treatment of trochanteric fractures. It is composed of a helical neck blade, a nail and a distal locking bolt. There were some reports of femoral shaft fractures even after the fractures were healed. The stress shielding effects of the PFNA device made of stiff titanium alloy on the bone-remodeling behavior of the host femur and the uneven distribution of interface shear stress may contribute to this complication. Recently, a new class of composite called functionally graded material (FGM) was developed, that consisted a gradual pattern of material composition and/or microstructures, and was introduced in dental implant and cementless hip stem. Accordingly, in this paper, we hypothesized that FGM might be used as the material of the nail in PFNA device with the material composition of the nail gradually shifting from more stiff at the proximal side of the femur to more flexible 'iso-elastic' towards the distal side. This hypothesis can be evaluated from the long-term remodeling behavior of host femur and the stress distributions in the PFNA device and bone.
Günther, Christian Max; Müller, Peter Ernst; Mutschler, Wolf; Sprecher, Christoph Martin; Milz, Stefan; Braunstein, Volker
In the management of proximal humeral fractures intramedullary implants with bent and straight shape of the proximal part of nail are available. Based on data from previous studies on bone distribution in the humeral head, we hypothesized, that higher densities might exist in the bone stock surrounding straight nails in comparison to their angulated counterparts. With a known positive correlation between bone density and mechanical stability, this could indicate potentially higher rigidity of osteosyntheses done with straight implants. We performed high resolution peripheral quantitative computed tomographies of the potential straight and bent implant bearing regions of 27 cadaveric proximal humeri. The acquired data were analyzed for differences between straight and bent Volumes of Interest as well as intra- and interindividual bone stock distribution. For both straight and bent volumes of interest a considerably declining bone mineral density was found in craniocaudal direction. Mean densities of bent volumes were significantly lower in comparison to their corresponding straight counterparts (p < 0.01) Intra-individual comparison yielded high bivariate correlations of the corresponding Volumes of Interest of the right and the left side (p < 0.01). Based on the volumetric data a statistically relevant biomechanical superiority of straight shaped implants can be assumed. Since we found a rapid decrease of bone density in cranio-caudal direction, intramedullary implants should be anchored as proximally in the subcortical area as possible to minimize the risk of displacement or cutout. The high correlation between the Volumes of Interest of the corresponding right and left sides could aid in preoperative planning when considering an intra- or extramedullary approach.
de Berker, D A R; André, J; Baran, R
The nail plate is the permanent product of the nail matrix. Its normal appearance and growth depend on the integrity of several components: the surrounding tissues or perionychium and the bony phalanx that are contributing to the nail apparatus or nail unit. The nail is inserted proximally in an invagination practically parallel to the upper surface of the skin and laterally in the lateral nail grooves. This pocket-like invagination has a roof, the proximal nail fold and a floor, the matrix from which the nail is derived. The germinal matrix forms the bulk of the nail plate. The proximal element forms the superficial third of the nail whereas the distal element provides its inferior two-thirds. The ventral surface of the proximal nail fold adheres closely to the nail for a short distance and forms a gradually desquamating tissue, the cuticle, made of the stratum corneum of both the dorsal and the ventral side of the proximal nail fold. The cuticle seals and therefore protects the ungual cul-de-sac. The nail plate is bordered by the proximal nail fold which is continuous with the similarly structured lateral nail fold on each side. The nail bed extends from the lunula to the hyponychium. It presents with parallel longitudinal rete ridges. This area, by contrast to the matrix has a firm attachment to the nail plate and nail avulsion produces a denudation of the nail bed. Colourless, but translucent, the highly vascular connective tissue containing glomus organs transmits a pink colour through the nail. Among its multiple functions, the nail provides counterpressure to the pulp that is essential to the tactile sensation involving the fingers and to the prevention of the hypertrophy of the distal wall tissue, produced after nail loss of the great toe nail.
Garret, J; Houdré, H; Cievet-Bonfils, M; Godenèche, Arnaud; Duparc, Fabrice; Roussignol, Xavier
Open reduction and internal fixation of complex proximal humeral fracture represents a surgical challenge. The main objective of this procedure is to anatomically reduce the tuberosities. We propose a standardized and reproducible technique that we apply to all complex displaced 3- and 4-part fractures of patients under 50 years. We use an antero-lateral trans-deltoid approach; the humeral head and the tuberosities are reduced under fluoroscopic control. The tuberosities are stabilized with an inter-tuberosity osteosuture, and we then introduce a thin and straight intra-medullary nail (Telegraph IV FH Orthopedics) at the hinge point of the humeral head. The osteosynthesis of the tuberosities is completed by 3- or 4-self-stable divergent screws in the nail. A dynamic distal locking stabilizes the humeral shaft in rotation and facilitates consolidation thanks to micro movements. The removal of the nail with an arthroscopic shoulder arthrolysis in case of stiffness is possible secondarily.
Palomo López, P; Becerro de Bengoa Vallejo, R; López López, D; Prados Frutos, J C; Alfonso Murillo González, J; Losa Iglesias, M E
The purpose of this study was to delineate the relationship of the terminal extensor hallucis longus tendon insertion to the proximal limit of the nail matrix of the great toe. Fifty fresh-frozen human cadaver great toes with no evidence of trauma (average age, 62.5 years; 29 males and 21 females) were used for this study. Under 25X magnification, the proximal limit of the nail matrix and the terminal bony insertion of the extensor hallucis longus tendons were identified. The distance from the terminal tendon insertion to the nail matrix was ascertained using precision calipers, an optical microscope, and autocad(®) software for windows. Twenty-five great toes were placed in a neutral formalin solution and further analysed by histological longitudinal-sections. The specimens were stained with haematoxylin and eosin and examined microscopically to determine the presence of the extensor hallucis longus tendon along the dorsal aspect of the distal phalanx of each great toe. The main result we found in great toes was that the extensor tendon is between the matrix and the phalanx and extends dorsally to the distal aspect of the distal phalanx in all, 100%, specimens. The nail matrix of the great toe is not attached to the periosteum of the dorsal aspect of the base of the distal phalanx as is the case for fingers, because the extensor hallucis tendon is plantar or directly underneath the nail matrix and the tendon is dorsal to the bone. We have found that the extensor tendon is between the matrix and the phalanx and extends dorsally to the distal aspect of the distal phalanx. The nail matrix of the great toe is not attached to the periosteum of the dorsal aspect of the base of distal phalanx as is the case in fingers, because the extensor hallucis tendon is plantar or directly underneath the nail matrix and the tendon is dorsal to the bone. Our anatomic study demonstrates that the proximal limit of the matrix and nail bed of the human great toe are dorsal and
Background Surgeons agree on the benefits of operative treatment of tibial fractures – the most common of long bone fractures – with an intramedullary rod or nail. Rates of re-operation remain high – between 23% and 60% in prior trials – and the two alternative nailing approaches, reamed or non-reamed, each have a compelling biological rationale and strong proponents, resulting in ongoing controversy regarding which is better. Methods/Design The objective of this trial was to assess the impact of reamed versus non-reamed intramedullary nailing on rates of re-operation in patients with open and closed fractures of the tibial shaft. The study to prospectively evaluate reamed intramedullary nails in tibial fractures (S.P.R.I.N.T) was a multi-center, randomized trial including 29 clinical sites in Canada, the United States and the Netherlands which enrolled 1200 skeletally mature patients with open (Gustilo Types I-IIIB) or closed (Tscherne Types 0–3) fractures of the tibial shaft amenable to surgical treatment with an intramedullary nail. Patients received a statically locked intramedullary nail with either reamed or non-reamed insertion. The first strategy involved fixation of the fracture with an intramedullary nail following reaming to enlarge the intramedullary canal (Reamed Group). The second treatment strategy involved fixation of the fracture with an intramedullary nail without prior reaming of the intramedullary canal (Non-Reamed Group). Patients, outcome assessors, and data analysts were blinded to treatment allocation. Peri-operative care was standardized, and re-operations before 6 months were proscribed. Patients were followed at discharge, 2 weeks post-discharge, and at 6 weeks, 3, 6, 9, and 12 months post surgery. A committee, blinded to allocation, adjudicated all outcomes. Discussion The primary outcome was re-operation to promote healing, treat infection, or preserve the limb (fasciotomy for compartment syndrome after nailing). The primary
Sadighi, Ali; Elmi, Asghar; Jafari, Mohamad Ali; Sadeghifard, Vahid; Goldust, Mohamad
Tibia fractures are the most common type of long bone fractures in US. This study aimed at comparing the therapeutic results of closed tibial shaft fracture with intramedullary nails inserted with and without reaming. In this randomized clinical trial study, 60 patients with a fracture of the tibia were examined. The patients were randomly divided into two groups. Thirty patients treated through inserting intramedullary nail with reaming technique (group A). The other 30 patients treated through inserting intramedullary nail without reaming technique (group B). After operation physical examination and control radiography were taken up to 6 month and results were compared. Sixty patients suffering from closed tibial diaphysis fractures were studied. Mean age of the group A and B were 40.24 +/- 12.32 and 38.42 +/- 14.28, respectively. Group A consisted of 24 (80%) males and 6 (20%) females while group B consisted of 24% females and 76% males. Considering fracture based on OTA criteria (p = 0.4) and severity of soft tissue damage based on Tscherne classification (p = 0.6), there was no statistically meaningful difference between groups A and B. The study demonstrated that degree of horizontal displacement, mean time of surgery, post-operation infection, organ shortness at the end of the follow-up period, organ deviation in patients of the group A was significantly more than that of the group B. Time required for callus formation (mean time of union), mean time of full weight bearing time and mean time of return to normal activities in group B was significantly more than that of the group A.
Introduction Both the isolated distal femoral epiphysiolysis and the isolated proximal tibial epiphysiolysis are the least common epiphyseal injuries. Even though they are uncommon, they have a high incidence rate of complications. Case presentation We present a case with Gustilo-Anderson grade 3b open and Salter-Harris type 1 epiphysiolysis of the distal femur and proximal tibia caused by a farm machinery accident. The patient was a 10-year-old boy, treated by open reduction and internal fixation. Conclusion Although distal femoral and proximal tibial growth plate injuries are rarely seen benign fractures, their management requires meticulous care. Anatomic reduction is important, especially to minimize the risk of growth arrest and the development of degenerative arthritis. However, there is a high incidence of growth arrest and neurovascular injury with these type of fractures. PMID:23724954
Gulabi, Deniz; Erdem, Mehmet; Bulut, Guven; Avci, Cem Coskun; Asci, Murat
Both the isolated distal femoral epiphysiolysis and the isolated proximal tibial epiphysiolysis are the least common epiphyseal injuries. Even though they are uncommon, they have a high incidence rate of complications. We present a case with Gustilo-Anderson grade 3b open and Salter-Harris type 1 epiphysiolysis of the distal femur and proximal tibia caused by a farm machinery accident. The patient was a 10-year-old boy, treated by open reduction and internal fixation. Although distal femoral and proximal tibial growth plate injuries are rarely seen benign fractures, their management requires meticulous care. Anatomic reduction is important, especially to minimize the risk of growth arrest and the development of degenerative arthritis. However, there is a high incidence of growth arrest and neurovascular injury with these type of fractures.
Gomes, Pedro Luciano Teixeira; Castelo, Luís Sá; Lopes, António Lemos; Maio, Marta; Miranda, Adélia; Dias, António Marques
Proximal femoral nails with a helical blade are a new generation of implants used for treating transtrochanteric fractures. The blade design provides rotational and angular stability for the fracture. Despite greater biomechanical resistance, they sometimes present complications. In the literature, there are some reports of cases of perforation of the femoral head caused by helical blades. Here, a clinical case of medial migration of the helical blade through the femoral head and acetabulum into the pelvic cavity is presented.
Jain, S; Harwood, P
We performed this systematic review to evaluate tibial lengthening procedures with the use of an intramedullary nail. We investigated the hypothesis that lengthening over a nail can reduce the time spent in an external fixator and increase the rate of consolidation thereby reducing the risk of complications and improving patient satisfaction. We conducted a comprehensive literature search using the MEDLINE, EMBASE and PubMed databases using the key words 'tibia' or 'tibial lengthening' and 'nail'. This search was performed in December 2011 and repeated by both authors. Specific outcome measures were the duration of external fixation, rate of consolidation and complication rates. A total of 6 comparative studies published between 2005 and 2011 consisting of 494 procedures met our inclusion and exclusion criteria and were eligible for critical appraisal. The methodological quality of the studies was variable, and they were not homogenous enough for meta-analysis. Patients who have tibial lengthening over an intramedullary nail spend significantly less time in an external fixator. However, there is no reliable evidence to suggest that the rates of consolidation or complication are any different to those lengthened without an intramedullary nail.
Konya, Mehmet Nuri; Verim, Özgür
Proximal femoral fracture rates are increasing due to osteoporosis and traffic accidents. Proximal femoral nails are routinely used in the treatment of these fractures in the proximal femur. To compare various combinations and to determine the ideal proximal lag screw position in pertrochanteric fractures (Arbeitsgemeinschaft für Osteosynthesefragen classification 31-A1) of the femur by using optimized finite element analysis. Biomechanical study. Computed tomography images of patients' right femurs were processed with Mimics. Afterwards a solid femur model was created with SolidWorks 2015 and transferred to ANSYS Workbench 16.0 for response surface optimization analysis which was carried out according to anterior-posterior (-10°
Karaarslan, Ahmet A; Karakaşli, Ahmet; Aycan, Hakan; Çeçen, Berivan; Yildiz, Didem Venüs; Sesli, Erhan
Background: Proximal locking screw deformation and screw fracture is a frequently seen problem for femur interlocking nailing that affects fracture healing. We realized that there is lack of literature for the right level for the proximal locking screw. We investigated the difference of locking screw bending resistance between the application of screws on different proximal femoral levels. Materials and Methods: We used a total of 80 proximal locking screws for eight groups, 10 screws for each group. Three-point bending tests were performed on four types of screws in two different trochanteric levels (the lesser trochanter and 20 mm proximal). We determined the yield points at three-point bending tests that a permanent deformation started in the locking screws using an axial compression testing machine. Results: The mean yield point value of 5 mm threaded locking screws applied 20 mm proximal of lesser trochanter was 1022 ± 49 (range 986–1057) (mean ± standard deviation, 95% confidence interval). On the other hand, the mean yield point value of the same type of locking screws applied on the lesser trochanteric level was 2089 ± 249 (range 1911–2268). Which means 103% increase of screw resistance between two levels (P = 0.000). In all screw groups, on the lesser trochanter line we determined 98–174% higher than the yield point values of the same type of locking screws in comparison with 20 mm proximal to the lesser trochanter (P = 0.000). Conclusion: According to our findings, there is twice as much difference in locking screw bending resistance between these two application levels. To avoid proximal locking screw deformation, locking screws should be placed in the level of the lesser trochanter in nailing of 1/3 middle and distal femur fractures. PMID:26955183
Spiegelberg, B G I; Speigelberg, B G I; Sewell, M D; Coltman, T; Blunn, G W; Flanagan, A M; Cannon, S R; Briggs, T W R
We report a case which highlights the progression of osteofibrous dysplasia to adamantinoma and questions whether intralesional curettage is the appropriate treatment. The role of a joint-sparing massive endoprosthesis using cortical fixation is demonstrated and we describe a unique biomedical design which resulted in the manufacture of an end cap to allow amputation through a custom-made proximal tibial replacement, rather than an above-knee amputation following recurrence.
Wang, Tie-Jun; Ju, Wei-Na; Qi, Bao-Chang
Abstract Rationale: Anatomical characteristics, such as subcutaneous position and minimal muscle cover, contribute to the complexity of fractures of the distal third of the tibia and fibula. Severe damage to soft tissue and instability ensure high risk of delayed bone union and wound complications such as nonunion, infection, and necrosis. Patient concerns: This case report discusses management in a 54-year-old woman who sustained fractures of the distal third of the left tibia and fibula, with damage to overlying soft tissue (swelling and blisters). Plating is accepted as the first choice for this type of fracture as it ensures accurate reduction and rigid fixation, but it increases the risk of complications. Diagnosis: Closed fracture of the distal third of the left tibia and fibula (AO: 43-A3). Interventions: After the swelling was alleviated, the patient underwent closed reduction and fixation with an Acumed fibular nail and minimally invasive plating osteosynthesis (MIPO), ensuring a smaller incision and minimal soft-tissue dissection. Outcomes: At the 1-year follow-up, the patient had recovered well and had regained satisfactory function in the treated limb. The Kofoed score of the left ankle was 95. Lessons: Based on the experience from this case, the operation can be undertaken safely when the swelling has been alleviated. The minimal invasive technique represents the best approach. Considering the merits and good outcome in this case, we recommend the Acumed fibular nail and MIPO technique for treatment of distal tibial and fibular fractures. PMID:28328865
Israni, Pratik; Panat, Mangesh
Fractures of the proximal tibial epiphysis rare. It has been estimated that fractures of the upper tibial epiphysis account for 0.5-3.1% of all epiphyseal injuries. Who had no neurovascular deficit, with fixed extension deformity at the left knee was treated early with closed reduction techniques. We present a case of a 16-year-old boy who while playing cricket on the road was hit by a car. The patient presented in emergency room with extremely swollen knee and soft tissue swelling (hemarthrosis), he was unable to lift his leg actively due to severe pain because of hamstrings spasm, and he had no wound over his left knee and had no other associated injuries. Plain radiographs were taken which revealed, separated proximal tibial epiphysis (salter harris Type 1 injury) The epiphysis was anteriorly displaced fracture line extending beyond growth plate through metaphysis and tibial tuberosity also displaced anteriorly, the proximal fibular epiphysis fragment was displaced anteriorly with no injury to femoral epiphysis and no patellar fracture, radiograph also revealed no intra-articular fracture as joint appears congruent. Under spinal anesthesia, under all aseptic precautions traction was applied for few minutes, the fracture was reduced closed as the hamstring spasm gave way, reduction was confirmed under image intensifier in both AP and lateral planes, and joint congruity was examined. Proximal fibular epiphysis also snapped back in place. Post-operative patient was immobilized with nil weight bearing for 4 weeks, check X-rays taken, he was mobilized in wheelchair. After 4 weeks slab was removed, K-wires were removed, and partial weight bearing was started with rehabilitation for full range of motion of the left knee. At 6 weeks, both the knee joints appeared symmetrical with no abnormalities or limb length discrepancy or instability with knee from 0° to 140°, with full weight bearing. Although less commonly seen, Salter-Harris Type 1 injuries to proximal tibial
Israni, Pratik; Panat, Mangesh
Introduction: Fractures of the proximal tibial epiphysis rare. It has been estimated that fractures of the upper tibial epiphysis account for 0.5-3.1% of all epiphyseal injuries. Who had no neurovascular deficit, with fixed extension deformity at the left knee was treated early with closed reduction techniques. Case Report: We present a case of a 16-year-old boy who while playing cricket on the road was hit by a car. The patient presented in emergency room with extremely swollen knee and soft tissue swelling (hemarthrosis), he was unable to lift his leg actively due to severe pain because of hamstrings spasm, and he had no wound over his left knee and had no other associated injuries. Plain radiographs were taken which revealed, separated proximal tibial epiphysis (salter harris Type 1 injury) The epiphysis was anteriorly displaced fracture line extending beyond growth plate through metaphysis and tibial tuberosity also displaced anteriorly, the proximal fibular epiphysis fragment was displaced anteriorly with no injury to femoral epiphysis and no patellar fracture, radiograph also revealed no intra-articular fracture as joint appears congruent. Under spinal anesthesia, under all aseptic precautions traction was applied for few minutes, the fracture was reduced closed as the hamstring spasm gave way, reduction was confirmed under image intensifier in both AP and lateral planes, and joint congruity was examined. Proximal fibular epiphysis also snapped back in place. Post-operative patient was immobilized with nil weight bearing for 4 weeks, check X-rays taken, he was mobilized in wheelchair. After 4 weeks slab was removed, K-wires were removed, and partial weight bearing was started with rehabilitation for full range of motion of the left knee. At 6 weeks, both the knee joints appeared symmetrical with no abnormalities or limb length discrepancy or instability with knee from 0° to 140°, with full weight bearing. Conclusion: Although less commonly seen, Salter
Ene, Răzvan; Sinescu, Ruxandra Diana; Ene, Patricia; Popescu, Dan; Cîrstoiu, Monica Mihaela; Cîrstoiu, Florin Cătălin
Osteosarcoma is the most common bone tumor that occurs in children and young adults with prevalence of teenage. There can be identified many subtypes of osteosarcoma by how they look on X-rays and under the microscope. Osteosarcoma can be classified as high-grade, intermediate grade, or low-grade. This has a significant prognostic value of tumor development suggesting the growth rate and the potential for expansion. Between 2009-2013, in the Department of Orthopedics and Traumatology, University Emergency Hospital of Bucharest, Romania, were treated seven cases of osteosarcoma of the proximal third of the tibia in young, early-diagnosed cases without metastasis. The treatment involved resection of tumor formation and reconstruction with a modular prosthesis. Postoperative patients were mobilized for a week without charging the operated limb under the protection of orthesis. During this period continued active and passive mobilization of the ankle and foot to prevent stiffness and to reduce postoperative swelling. From the second postoperative week, patients are mobilizing with progressive charging but not being allowed to do any flexion in order to protect de insertion of medial gastrocnemius muscle rotation flap used to cover the prosthesis and to protect the patellar tendon reinsertion. This extensive surgery does not improve survival rate of these patients compared to treatment by amputation of this pathology but greatly increases the comfort of life and in all cases ensure socio-professional reintegration of these patients. To ensure optimal postoperative results perform a complete diagnosis and preoperative oncological treatment before surgery, if applicable.
Limb salvage in tumor surgery has encouraged the development of megaprostheses. However, reattaching the ligamentum patellae poses a particular problem: avulsion and/or extensor lag may lead to poor function. We describe a new technique of patellar ligament reconstruction. The technique involves reattachment of the patellar ligament to the tibial tuberosity of the proximal tibial megaprosthesis, which has a porous surface created, and the repair is protected with a cerclage wire through the patella and the prosthesis. In 10 consecutive patients, the range of motion averaged 95° (median, 90°; range, 70°–120°), and the mean extension lag averaged 4° (median, 0°; range, 0°–20°). We had one case of patellar ligament avulsion. This technique resulted in good quadriceps function and a low incidence of complications. Level of Evidence: Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence. PMID:18425561
Whately, Chris; Abdallah, Mohamed Attia; Alwatari, Yahya Ahmed
Tibia accounts for the majority of open fractures with long segmental defects. The management of such defects imposes several challenges due to their associations with extensive soft tissue damage and high infection risk. In this report, we describe a new technique for the reconstruction of tibia in a young patient with 10 cm defect. The patient had a history of Gustilo Anderson type IIIB open fracture following a motorcycle accident. He was initially managed with multiple debridements and application of an external fixator. The defect was treated with the insertion of an antibiotic-coated intramedullary nail along with posterolateral bone grafting using an absorbable mesh. Six months postoperative, radiological assessment showed excellent callus formation diffusely around the intramedullary nail along with optimal alignment. The preliminary follow-up data are quite encouraging and the technique described in our case can be considered as a reasonable option in managing long segmental bone defects. PMID:23887993
Hackl, S; Merkel, P; Hungerer, S; Friederichs, J; Müller, N; Militz, M; Bühren, V
Pyoderma gangrenosum is a rare non-infectious neutrophilic dermatitis, whereas necrotizing fasciitis is a life-threatening bacterial soft tissue infection of the fascia and adjacent skin. As in the case described here after intramedullary nailing, the clinical appearance of both diseases can be similar. Because of the completely different therapeutic approach and a worse outcome in the case of false diagnosis, pyoderma gangrenosum should always be taken into consideration before treating necrotizing fasciitis.
Karaarslan, Ahmet Adnan; Karakaşli, Ahmet; Karci, Tolga; Aycan, Hakan; Yildirim, Serhat; Sesli, Erhan
The aim is to present our new method of compression, a compression tube instead of conventional compression screw and to investigate the difference of proximal locking screw bending resistance between compression screw application (6 mm wide contact) and compression tube (two contact points with 13 mm gap) application. We formed six groups each consisting of 10 proximal locking screws. On metal cylinder representing lesser trochanter level, we performed 3-point bending tests with compression screw and with compression tube. We determined the yield points of the screws in 3-point bending tests using an axial compression testing machine. We determined the yield point of 5 mm screws as 1963±53 N (mean±SD) with compression screw, and as 2929±140 N with compression tubes. We found 51% more locking screw bending resistance with compression tube than with compression screw (p=0,000). Therefore compression tubes instead of compression screw must be preferred at femur compression nails.
Wedin, R; Bauer, H C F
We report positive and negative factors associated with the most commonly-used methods of reconstruction after pathological fracture of the proximal femur. The study was based on 142 patients treated surgically for 146 metastatic lesions between 1996 and 2003. The local rate of failure was 10.3% (15 of 146). Of 37 operations involving osteosynthetic devices, six failed (16.2%) compared with nine (8.3%) in 109 operations involving endoprostheses. Of nine cases of prosthetic failure, four were due to periprosthetic fractures and three to recurrent dislocation. In the osteosynthesis group, three (13.6%) of 22 reconstruction nails failed. The two-year risk of re-operation after any type of osteosynthesis was 0.35 compared with 0.18 after any type of endoprosthetic reconstruction (p = 0.07). Endoprosthetic reconstructions are preferable to the use of reconstruction nails and other osteosynthetic devices for the treatment of metastatic lesions in the proximal third of the femur.
Alho, A; Ekeland, A; Grøgaard, B; Dokke, J R
Twenty-seven patients with complex femoral fractures (combined shaft and proximal femoral fractures) were treated with a modified Grosse-Kempf slotted locking nail (cephalomedullary nail), wherein two screws were inserted in the hip. Four types of complex, multifocal femoral fractures were represented in the series. Eleven of the femoral shaft fractures were secondary to a previous, internally fixed, not yet united hip fracture (type I). Ten comminuted peritrochanteric fractures occurred in normal bone (type II). Three similar fractures were pathologic because of metastasis. Two patients had an ipsilateral fracture of the femoral shaft and the trochanteric area (type III), and one of the shaft and the femoral neck (type IV). Locking was made static in 24 cases. Additional cerclage wiring was used in three type II fractures. Five complications were as follows: one cutting out of a screw in the femoral head, two fractures of the nail, one deep venous thrombosis, and one wound hematoma. Reoperations were two salvage operations using a new nail and one evacuation of hematoma. One patient with multiple injuries and four elderly patients died within 2 months. Eighteen patients with fractures in normal bone were followed for a median of 20 (6 to 37) months. All fractures united. Two nails were removed. The end result was excellent in ten patients, good in seven, and fair in one (2-cm shortening and 20-degree external rotation). We conclude that a locked intramedullary construct with locking screws in femoral neck and distal femur controls a complex fracture situation well.
Domzalski, Marcin; Mackenzie, William
Two cases of asymmetrical closure of the proximal tibial epiphysis without a clear aetiological factor were presented. In both cases premature closure of the growth plate resulted in progressive recurvatum and valgus deformity of the knee with leg length discrepancy. The correction of deformity was obtained using Taylor Spatial frame with excellent results at 2 years follow-up. We hypothesize that repetitive trauma or chronic overloading during sports activities might be a factor of growth arrest in reported cases. Orthopedic surgeons should be aware of the possibility of subtle physeal injuries, causing angular deformities, in the cases of even minor knee trauma in skeletally immature population.
Kim, Joon-Woo; Oh, Chang-Wug; Oh, Jong-Keon; Kyung, Hee-Soo; Park, Kyeong-Hyeon; Kim, Hee-June; Jung, Jae-Wook; Jung, Young-Soo
High-energy proximal tibial fractures often accompany compartment syndrome and are usually treated by fasciotomy with external fixation followed by secondary plating. However, the initial soft tissue injury may affect bony union, the fasciotomy incision or external fixator pin sites may lead to postoperative wound infections, and the staged procedure itself may adversely affect lower limb function. We assess the results of staged minimally invasive plate osteosynthesis (MIPO) for proximal tibial fractures with acute compartment syndrome. Twenty-eight patients with proximal tibial fractures accompanied by acute compartment syndrome who underwent staged MIPO and had a minimum of 12 months follow-up were enrolled. According to the AO/OTA classification, 6 were 41-A, 15 were 41-C, 2 were 42-A and 5 were 42-C fractures; this included 6 cases of open fractures. Immediate fasciotomy was performed once compartment syndrome was diagnosed and stabilization of the fracture followed using external fixation. After the soft tissue condition normalized, internal conversion with MIPO was done on an average of 37 days (range, 9-158) after index trauma. At the time of internal conversion, the external fixator pin site grades were 0 in 3 cases, 1 in 12 cases, 2 in 10 cases and 3 in 3 cases, as described by Dahl. Radiographic assessment of bony union and alignment and a functional assessment using the Knee Society Score and American Orthopedic Foot and Ankle Society (AOFAS) score were carried out. Twenty-six cases achieved primary bony union at an average of 18.5 weeks. Two cases of nonunion healed after autogenous bone grafting. The mean Knee Society Score and the AOFAS score were 95 and 95.3 respectively, at last follow-up. Complications included 1 case of osteomyelitis in a patient with a grade IIIC open fracture and 1 case of malunion caused by delayed MIPO due to poor wound conditions. Duration of external fixation and the external fixator pin site grade were not related to the
Vincenti, S; Knell, S; Pozzi, A
Caudal cruciate ligament injury can be a complication following tibial plateau leveling osteotomy (TPLO) (Slocum und Slocum, 1993) especially if the post-operative Tibial Plateau Angle (TPA) is less than 5 degree. We describe a case of negative TPA associated with partial cranial and caudal ligament rupture treated with a center of rotation of angulation (CORA) based cranial tibial opening wedge osteotomy and tibial tuberosity transposition. A 13 kg, mixed breed dog was presented for right pelvic limb lameness. Radiographically a bilateral patella baja and a malformed tibia tuberosity along with a bilateral TPA of -8 degree were detected. Arthroscopically a partial rupture of the cranial and caudal cruciate ligaments were found. A cranial tibial opening wedge osteotomy of 23 degree and a fibular ostectomy were performed. The osteotomy was fixed with a 8 holes ALPS 9 (KYON, Switzerland) and a 3-holes 2.0mm UniLock plate (Synthes, Switzerland). Then a proximal tibial tuberosity transposition of 10mm was performed and fixed with a pin and tension band construct. The postoperative TPA was 15 degree. The radiographic controls at 6, 10 weeks, 6 months and 1 year after surgery revealed an unchanged position of the implants and progressive healing of the osteotomies. At the 6 and 12 months recheck evaluation the dog had no evidence of lameness or stifle pain and radiographs revealed complete healing of the osteotomy site and no implant failure. The diaphyseal CORA based osteotomy allowed accurate correction of a proximal tibial deformity associated with negative TPA.
Sitthiseripratip, Kriskrai; Mahaisavariya, Banchong; Suwanprateeb, Jintamai; Bohez, Erik; Vander Sloten, Jos
The purpose of this study was to investigate the influence of lateral muscle loading on the stress/strain distributions of the trochanteric Gamma nail (TGN) fixation within the healed, trochanteric and subtrochanteric femoral fractures by means of a finite element method. The effect of three muscle groups, the abductors (ABD), the vastus lateralis (VL) and the iliotibial band (ITB), were investigated. The analytical results showed that addition of lateral muscle forces, iliotibial band and vastus lateralis, produced compensation of forces and reduction of bending moments in the bone and in the trochanteric Gamma nail especially in the lateral aspect. The iliotibial band produced a higher impact as compared to the vastus lateralis. Therefore in the finite element analysis of the proximal femur with the trochanteric Gamma nail fracture fixation should include the lateral muscle forces to simulate load condition with maximal physiological relevance to the closed nailing technique.
Sell, Timothy C; Akins, Jonathan S; Opp, Alexis R; Lephart, Scott M
Proximal anterior tibia shear force is a direct loading mechanism of the anterior cruciate ligament (ACL) and is a contributor to ACL strain during injury. Measurement of this force during competition may provide insight into risk factors for ACL injury. Accelerometers may be capable of measuring tibial acceleration during competition. The purpose of this study was to examine the relationship between acceleration measured by a tibia-mounted accelerometer and proximal anterior tibia shear force as measured through inverse dynamics and peak posterior ground reaction forces during two leg stop-jump tasks. Nineteen healthy male subjects performed stop-jump tasks across increasing jump distances. Correlation coefficients were calculated to determine if a relationship exists between accelerometer data and proximal anterior tibia shear force and peak posterior ground reaction force. An analysis of variance was performed to compare these variables across jump distance. Significant correlations were observed between accelerometer data and peak posterior ground reaction force, but none between accelerometer data and proximal anterior tibia shear force. All variables except peak proximal anterior tibia shear force increased significantly as jump distance increased. Overall, results of this study provide initial, positive support for the use of accelerometers as a useful tool for future injury prevention research.
Haddad, Behrooz; Konan, Sujith; Mannan, Ken; Scott, Gareth
We measured the posterior tibial slope for the medial and lateral tibial plateau separately in MR images of 143 knees (71 women, 72 men) and compared the measurements between genders and different ethnic groups. For the whole population the mean medial slope was 5.7 degrees and the mean lateral slope 5.6 degrees. There was a significant difference between the medial and lateral posterior tibial slope in the Asian patients compared with other ethnic groups (p < 0.001). We have shown that measurement of the posterior tibial slope (PTS) could be reliably performed on MR images, revealing a gender difference. These findings might have clinical relevance when performing reconstructive surgery at the knee in determining ideal placement of the tibial component.
Bhandari, Mohit; Tornetta, Paul; Rampersad, Shelly-Ann; Sprague, Sheila; Heels-Ansdell, Diane; Sanders, David W; Schemitsch, Emil H; Swiontkowski, Marc; Walter, Stephen
Inadequate sample size and power in randomized trials can result in misleading findings. This study demonstrates the effect of sample size in a large clinical trial by evaluating the results of the Study to Prospectively evaluate Reamed Intramedullary Nails in Patients with Tibial fractures (SPRINT) trial as it progressed. The SPRINT trial evaluated reamed versus unreamed nailing of the tibia in 1226 patients, and in open and closed fracture subgroups (N = 400 and N = 826, respectively). We analyzed the reoperation rates and relative risk comparing treatment groups at 50, 100, and then increments of 100 patients up to the final sample size. Results at various enrollments were compared with the final SPRINT findings. In the final analysis, there was a statistically significant decreased risk of reoperation with reamed nails for closed fractures (relative risk reduction 35%). Results for the first 35 patients enrolled suggested that reamed nails increased the risk of reoperation in closed fractures by 165%. Only after 543 patients with closed fractures were enrolled did the results reflect the final advantage for reamed nails in this subgroup. Similarly, the trend toward an increased risk of reoperation for open fractures (23%) was not seen until 62 patients with open fractures were enrolled. Our findings highlight the risk of conducting a trial with insufficient sample size and power. Such studies are not only at risk of missing true effects but also of giving misleading results.
Hill, Brian W; Rizkala, Amir R; Li, Mengnai
Pediatric proximal tibial epiphysis fractures are uncommon and have subsequently received little attention in terms of treatment and outcomes. We studied the clinical and functional outcomes of 13 patients with Salter-Harris III and IV fractures of the proximal tibial epiphysis after operative fixation. Associated meniscus, ligamentous, or neurovascular injury was present in 100% of this cohort. Provisional external fixation and locked plating spanning the open physis were used in the majority of cases. The mean clinical follow-up was 15.69 months, where all fractures progressed to union. Good functional outcomes with a low complication rate are possible after operative fixation of these infrequent injuries.
Li, Ying; Spencer, Samantha A; Hedequist, Daniel
Four percent of children and adolescents in the United States are morbidly obese. Treatment for tibia vara includes proximal tibial osteotomy and correction with a Taylor Spatial Frame (TSF). There are no reports that specifically examine the success of this technique in morbidly obese adolescents. A retrospective review was conducted of patients between 12 and 18 years of age with a body mass index for age at or above the 99th percentile who had undergone gradual correction of tibia vara with proximal tibial osteotomy and application of a TSF at our institution between 2005 and 2009. Deformity analysis was performed on full-length standing anteroposterior radiographs of both lower extremities and lateral radiographs of the involved tibia obtained preoperatively and at latest follow-up. All complications were recorded. Fourteen patients met the inclusion criteria. The mean age was 13 years. The average body mass index was 45 kg/m. Preoperative deformity analysis demonstrated a mean mechanical axis deviation of 90 mm, mean mechanical medial proximal tibial angle of 66 degrees, and mean posterior proximal tibial angle of 80 degrees. Analysis at an average follow-up of 14 months demonstrated a mean mechanical axis deviation of 10 mm, mean mechanical medial proximal tibial angle of 88 degrees, and mean posterior proximal tibial angle of 81 degrees. Complications specifically related to the TSF occurred in 2 patients. Both experienced strut disengagement and loss of osteotomy position. This was treated with refastening of the strut and a new program of deformity correction. Complications related to the deformity correction occurred in 3 patients. One had premature fibular consolidation requiring repeat osteotomy, 1 developed a transient partial deep peroneal nerve palsy, and 1 experienced thigh soft tissue irritation from the proximal ring necessitating early TSF removal. One patient had a residual leg-length discrepancy that required tibial lengthening. Correction of
Beslikas, Theodoros; Christodoulou, Andreas; Chytas, Anastasios; Gigis, Ioannis; Christoforidis, John
Salter-Harris type V fracture is a very rare injury in the immature skeleton. In most cases, it remains undiagnosed and untreated. We report a case of genu recurvatum deformity in a 15-year-old boy caused by a Salter-Harris type V fracture of the proximal tibial physis. The initial X-ray did not reveal fracture. One year after injury, genu recurvatum deformity was detected associated with significant restriction of knee flexion and limp length discrepancy (2 cm) as well as medial and posterior instability of the joint. Further imaging studies revealed anterior bone bridge of the proximal tibial physis. The deformity was treated with a high tibial dome osteotomy combined with a tibial tubercle osteotomy stabilized with malleolar screws and a cast. Two years after surgery, the patient gained functional knee mobility without clinical instability. Firstly, this case highlights the importance of early identification of this rare lesion (Salter-Harris type V fracture) and, secondly, provides an alternative method of treatment for genu recurvatum deformity.
Beslikas, Theodoros; Christodoulou, Andreas; Chytas, Anastasios; Gigis, Ioannis; Christoforidis, John
Salter-Harris type V fracture is a very rare injury in the immature skeleton. In most cases, it remains undiagnosed and untreated. We report a case of genu recurvatum deformity in a 15-year-old boy caused by a Salter-Harris type V fracture of the proximal tibial physis. The initial X-ray did not reveal fracture. One year after injury, genu recurvatum deformity was detected associated with significant restriction of knee flexion and limp length discrepancy (2 cm) as well as medial and posterior instability of the joint. Further imaging studies revealed anterior bone bridge of the proximal tibial physis. The deformity was treated with a high tibial dome osteotomy combined with a tibial tubercle osteotomy stabilized with malleolar screws and a cast. Two years after surgery, the patient gained functional knee mobility without clinical instability. Firstly, this case highlights the importance of early identification of this rare lesion (Salter-Harris type V fracture) and, secondly, provides an alternative method of treatment for genu recurvatum deformity. PMID:23259115
de Berker, David
The nail unit comprises the nail plate, the surrounding soft tissues, and their vasculature and innervation based upon the distal phalanx. The nail plate is a laminated keratinized structure lying on the nail matrix (15-25%), the nail bed with its distal onychodermal band (75-85%), and the hyponychium at its free edge. The distal part of the matrix, the lunula characterized by its half-moon shape, can be observed in some digits. The nail plate is embedded by the proximal and lateral folds. From the proximal nail fold, the cuticle (also known as the eponychium), adheres to the superficial surface of the proximal nail plate. The nail unit possesses a complex and abundant vascular network to ensure adequate blood supply. Finally, both the periungual soft tissues and the nail folds are innervated. The shapes, structure, and inter-relationships of these tissues are factors in the way nails present with disease and how we understand and manage those diseases. In particular, an understanding of the surgical anatomy is important for those undertaking diagnostic or curative operations on the nail. With this knowledge, the most appropriate surgery can be planned and the patient can be provided with accurate and clear guidance to enable informed consent.
Abdelgawad, Amr A
Infantile Blount’s disease is a condition that causes genu varum and internal tibial torsion. Treatment options include observation, orthotics, corrective osteotomy, elevation of the medial tibial plateau, resection of a physeal bar, lateral hemi-epiphysiodesis, and guided growth of the proximal tibial physis. Each of these treatment options has its disadvantages. Treating the coronal deformity alone (genu varum) will result in persistence of the internal tibial torsion (the axial deformity). In this report, we describe the combination of lateral growth modulation and distal tibial external rotation osteotomy to correct all the elements of the disease. This has not been described before for treatment of Blount’s disease. Both coronal and axial deformities were corrected in this patient. We propose this combination (rather than the lateral growth modulation alone) as the method of treatment for early stages of Blount’s disease as it corrects both elements of the disease and in the same time avoids the complications of proximal tibial osteotomy. PMID:23610758
Zhang, F; Zhu, Y; Li, W; Chen, W; Tian, Y; Zhang, Y
There remains a controversy between unreamed intramedullary nailing and external fixation to treat Gustilo grade IIIB tibial fractures. To evaluate the comparative effectiveness and safeness of both methods for this type of fracture, we performed this meta-analysis. Relevant original studies were searched in MEDLINE, EMBASE, China National Knowledge Infrastructure, and Cochrane Central Database (all through February 2014). Studies included in this meta-analysis had to compare the effectiveness or complications and provided sufficient data of interest. The patients treated by both methods were similar statistically in demography and injury mechanism. The Stata 11.0 was used to analyze all data. Six studies involving 163 participants were included. Unreamed intramedullary nailing was associated with reduced time to union (standardized mean difference, -1.14; 95% confidence interval, -2.04 to -0.24) and lower rates of superficial infection (odds ratio: 0.39; 95% confidence interval: 0.17-0.87) and malunion (odds ratio: 0.27; 95% confidence interval: 0.09-0.78). However, there were no significant differences in other adverse events including delayed union, non-union, deep infection, and fixation failure. The existing evidence supports unreamed intramedullary nailing to be a better method for treating Gustilo grade IIIB tibial fractures, and this might aid in the management of this sever injury. © The Finnish Surgical Society 2015.
Parkkinen, Markus; Madanat, Rami; Lindahl, Jan; Mäkinen, Tatu J
The risk factors are unclear for deep surgical site infection after plate fixation of proximal tibial fractures. The objective of this study was to identify the patient and surgical procedure-related risk factors for infection using established criteria for deep surgical site infection. A total of 655 proximal tibial fractures were treated with open reduction and plate fixation at our center between 2004 and 2013. We identified 34 patients with deep surgical site infection. A control group of 136 patients was randomly selected from the non-infected cohort. Potential risk factors for deep surgical site infection were identified by reviewing surgical, medical, and radiographic records. Independent risk factors for infection were identified from multivariable logistic regression analysis using a stepwise procedure. The prevalence of deep surgical site infection was 5.2%, the mean age of affected patients was 55 years (range, 16 to 84 years), and 35% of patients were female. Twenty-eight of 34 deep infections were diagnosed within 2 months (acute onset), and only 6 infections were diagnosed >6 months after the index surgical procedure. Nine of the 28 acute-onset infections were treated with antibiotic therapy and debridement. Seventeen patients (50%) required muscle flap coverage, and 5 patients (15%) eventually required above-the-knee amputation. In the multivariable logistic regression analysis with odds ratios (ORs) and 95% confidence intervals (95% CIs), independent predictors of infection were patient age of ≥50 years (OR, 3.6 [95% CI, 1.3 to 10.1]); obesity, defined as a body mass index of ≥30 kg/m(2) (OR, 6.5 [95% CI, 2.2 to 18.9]); alcohol abuse (OR, 6.7 [95% CI, 2.4 to 19.2]); OTA/AO-type-C fracture (OR, 2.8 [95% CI, 1.1 to 7.5]); use of a temporary spanning external fixator (OR, 3.9 [95% CI, 1.4 to 11.1]); and a 4-compartment fasciotomy (OR, 4.5 [95% CI, 1.3 to 15.7]). There is high morbidity associated with deep surgical site infection in plated proximal
Makki, Daoud; Matar, Hosam E; Jacob, Nebu; Lipscombe, Stephen; Gudena, Ravindra
Reverse oblique intertrochanteric fractures have unique mechanical characteristics and are often treated with intramedullary implants. We compared the outcomes of the reconstruction trochanteric antegrade nail (TAN) with the proximal femoral nail antirotation (PFNA). Between July 2008 and February 2014, we reviewed all patients with reverse oblique intertrochanteric fractures treated at our hospital. Patients with pathological fractures and those who were treated with other than TAN and PFNA nailing systems were excluded. Preoperative assessment included the Abbreviated mental test score (AMT), the ASA grade, pre-injury mobility and place of residence. Postoperative outcome measures included the type of implant used, time to fracture union, failures of fixation and revision surgeries. Fifty-eight patients were included and divided into two groups based on the treatment: 22 patients treated with TAN and 36 patients treated with PFNA systems. The two groups were well matched with regards to demographics and fracture type. The overall union rate was similar in both groups but the time to union was shorter in the TAN group. There were 8 implant failures in the PFNA (22.2%) group compare to none in the TAN group. Implant failure was associated with the severity of fracture (AO 31.A3.3) but was not related to fracture malreduction or screw position (Tip-apex-distance). Our study suggests that the use of reconstruction system with two screws such as TAN may be more suitable implant for reverse oblique intertrochanteric hip fractures.
Barkhaus, Paul E; Kincaid, John C; Nandedkar, Sanjeev D
The amplitude of the compound muscle action potential (CMAP) of abductor hallucis (AH) shows the largest drop with proximal stimulation of any routinely studied motor nerves. The cause has not been established. Four experiments of tibial motor nerve conduction in several healthy control subjects were performed using far-field recordings, collision, H-reflex, and intramuscular recordings of foot muscles. The proximal CMAP showed a mean peak-peak amplitude of 66% (range 57-79%) compared with the distal response. Collision and H-reflex recordings in AH did not show evidence of a contribution from the tibial-innervated calf muscle. Needle electrode recordings of CMAPs showed consistently different latencies between different foot muscles. Our experiments indicate that temporal dispersion and phase cancellation between the distal tibial-innervated foot muscles recorded by the E2 (i.e., reference) electrode can explain the drop in amplitude between the proximal and distal tibial evoked CMAP. Copyright © 2011 Wiley Periodicals, Inc.
Khan, A; Athlani, L; Rousset, M; Samba, A; Canavese, F
Displaced proximal humerus fractures within the pediatric population can be treated by elastic stable intramedullary nailing (ESIN). The main objective of our study is to evaluate functional outcome of the displaced proximal humeral fractures treated by ESIN within the pediatric group using a standardized evaluation scale. The secondary goal is to compare functional outcome of epiphyseal and metaphyseal injuries and functional outcome of children younger and older than 10 years of age. From March 2010 to December 2011, 27 children had been treated surgically using ESIN for displaced fractures at the proximal extremity of the humerus. These fractures were displaced and closed without neurovascular insult. Patients were followed radiographically and clinically on a regular basis. After hardware removal, the functional outcomes had been homogeneously assessed by using the French edition of the QuickDash(®) evaluation scale. The descriptive statistics including mean, standard deviation, and confidence interval have been realized. We included 27 children who were operated on consecutively (10 boys, 17 girls). The mean age at the time of operation is 11.2 ± 2.7 years (range 7.1-15.9). The mean angulation is 55.9° ± 20.3° (range 20-90). The mean apposition is 52.8 % ± 33.1 (range 10-100). The mean follow-up period is 15.2 ± 5.6 months (range 6.1-28.5). Results were considered good for children between 7.1 and 15.9 years old with epiphyseal and meataphyseal fractures. The mean QuickDash(®) score is 2.0 (range 0-6.5), with 14 cases showing a score of 0 (58.3 %), 2 cases with 4.3 (8.3 %), 4 cases with 4.5 (16.7 %), and 4 cases with a score of 6.5 (16.7 %). Ranges of movement were preserved. The patients regained their daily and sportive activity over the time without pain or discomfort. Our study showed a good outcome of functional results within a pediatric population who had a sustained displaced proximal humeral fracture and treated by ESIN. Using a standardized
Park, Jin-Young; An, Jin-Woo; Oh, Jeong-Hwan
To reduce complications and increase fixation after the internal fixation of proximal humeral fractures, interlocking intramedullary nailing and tension-band and locking sutures were used simultaneously, and their results are reviewed. Twenty-six consecutive patients who underwent open intramedullary nailing with tension-band and locking sutures for proximal humeral fractures were selected. The mean follow-up period was 39 months. With regard to the functional evaluation, the mean Neer score was 90 points and the mean American Shoulder and Elbow Surgeons score was 85. When patients were divided into those aged less than 65 years and those aged 65 years or greater and into those with 2-part fractures and those with 3-part fractures, postoperative pain, the American Shoulder and Elbow Surgeons score, and the Neer score showed no difference between the 2 groups. Open intramedullary nailing accompanied by tension-band and locking sutures for proximal humeral fractures shows sufficient fixation in older patients, and therefore, good postoperative shoulder function can be expected.
Neuerburg, C; Mehaffey, S; Gosch, M; Böcker, W; Blauth, M; Kammerlander, C
Use of standardized cement augmentation of the proximal femur nail antirotation (PFNA) for the treatment of trochanteric fragility fractures, which are associated with high morbidity and mortality, to achieve safer conditions for immediate full weight-bearing and mobilization, thus, improving preservation of function and independency of orthogeriatric patients. Trochanteric fragility fractures (type 31-A1-3). Ipsilateral arthritis of the hip, leakage of contrast agent into the hip joint, femoral neck fractures. Reduction of the fracture on a fracture table if possible, or minimally invasive open reduction of the proximal femur, i. e., using collinear forceps if necessary. Positioning of guidewires for adjustment of the PFNA and the spiral blade, respectively. Exclusion of leakage of contrast agent and subsequent injection of TRAUMACEM™ V(+) into the femoral head-neck fragment via a trauma needle kit introduced into the spiral blade. Dynamic or static locking of the PFNA at the diaphyseal level. Immediate mobilization of the patients with full weight-bearing and secondary prevention, such as osteoporosis management is necessary to avoid further fractures in the treatment of these patients. A total of 110 patients older than 65 years underwent the procedure. Of the 72 patients available for follow-up (average age 85.3 years), all fractures healed after an average of 15.3 months. No complications related with cement augmentation were observed. Approximately 60 % of patients achieved the mobility level prior to trauma.
Touraine, Sébastien; Ea, Hang Korng; Bousson, Valérie; Cohen-Solal, Martine; Laouisset, Liess; Chappard, Christine; Lioté, Frédéric; Laredo, Jean-Denis
Objectives To analyze calcium deposits by computed tomography (CT) in femoro-tibial compartments and proximal tibio-fibular joints; to assess the relationship with CT-assessed osteoarthritis (OA). Methods 68 (34 pairs) cadaveric knees (mean age of 84) were scanned at high resolution CT. Menisci and hyaline cartilage calcifications in the femoro-tibial and proximal tibio-fibular joints were analyzed. OA was CT-assessed by the Kellgren and Lawrence score. Gross appearance of OA was evaluated on 29 left knees after dissection and India ink staining of tibial plateaus. Results In femoro-tibial joints, meniscal calcifications (MC) and hyaline cartilage calcifications (HCC) were detected in 23(34%) and 14(21%) knees respectively. Calcifications mainly involved the three meniscal segments and were mainly observed in all thirds of the femoro-tibial compartments. In proximal tibio-fibular joints, HCC were detected in 19(28%) knees. The association HCC-MC in femoro-tibial joints and between calcifications in femoro-tibial and proximal tibio-fibular joints was strong (p<0.0001). Femoro-tibial and proximal tibio-fibular CT-assessed OA were respectively found in 23(34%) and 19(28%) knees. HCC were significantly associated with femoro-tibial OA (p = 0.04) while MC were not (p = 0.34). OA macroscopic evaluation showed a mean surface of cartilage lesions of 35% (range 0.13–0.55). No significant difference was demonstrated regarding the CT-detection of MC, HCC or CT-assessed OA. Conclusions This is the first study to report a strong association of chondrocalcinosis between femoro-tibial and tibio-fibular joints in addition to a strong association between MC and HCC in femoro-tibial compartments. No significant relationship between chondrocalcinosis and OA was demonstrated. PMID:23372802
Popkov, A. V.; Kononovich, N. A.; Gorbach, E. N.; Tverdokhlebov, S. I.; Irianov, Y. M.; Popkov, D. A.
Purpose. Our research was aimed at studying the radiographic and histological outcomes of using flexible intramedullary nailing (FIN) combined with Ilizarov external fixation (IEF) versus Ilizarov external fixation alone on a canine model of an open tibial shaft fracture. Materials and Methods. Transverse diaphyseal tibial fractures were modelled in twenty dogs. Fractures in the dogs of group 1 (n = 10) were stabilized with the Ilizarov apparatus while it was combined with FIN in group 2 (n = 10). Results. On day 14, a bone tissue envelope started developing round the FIN wires. Histologically, we revealed only endosteal bone union in group 1 while in group 2 the radiographs revealed complete bone union on day 28. At the same time-point, the areas of cancellous and mature lamellar bone tissues were observed in the intermediary area in group 2. The periosteal layers were formed of the trabeculae net of lamellar structure and united the bone fragments. The frame was removed at 30 days after the fracture in group 2 and after 45 days in group 1 according to bone regeneration. Conclusion. The combination of the Ilizarov apparatus and FIN accelerates bone repair and augments stabilization of tibial shaft fractures as compared with the use of the Ilizarov fixation alone. PMID:25379523
Song, Won Seok; Cho, Wan Hyeong; Jeon, Dae-Geun; Kong, Chang-Bae; Duo, Jian; Lee, Soo-Yong
Although previous reports on composite biologic reconstruction in the proximal tibial location vary, we hypothesized that this type of reconstruction may reduce the late infection rate and have advantages in terms of longevity by restoring bone stock. Primary analysis addressed differences between 62 tumor prosthesis (TP) and 25 pasteurized autograft-prosthesis composite (PPC) reconstructions in terms of survival rates, functional outcomes, and temporal patterns of infection. The 10-year survival rates of the TP and PPC groups were 73.9 ± 11.7 and 68.7 ± 20.1 %, respectively (P = 0.64). Reconstructive failure occurred in 16 (25.8 %) in the TP and in 7 (28 %) in the PPC group. The cause of failures in the TP group was infection (16), whereas those of PPC group were infection (5), loosening (1), and local recurrence (1). The mean functional scores of TP (52) and PPC (20) patients that maintained a mobile joint were 24.2 (81 %) and 25.1 (83.6 %), respectively. Infection rates in the two groups were similar (P = 0.328), but infections occurred earlier in the PPC group (P = 0.011). This comparative study suggests composite biological reconstruction shows a comparable long-term survival rate to TP reconstruction; however, the composite method has a tendency to a lower rate of late infection.
Gong, Jinpeng; Liu, Pengcheng; Cai, Ming
Background Proximal femoral nail anti-rotation (PFNA) is a standard femoral intertrochanteric fracture operation. Iatrogenic vascular injury, although uncommon, is a reported complication of PFNA surgery as well as a complication of hip fracture surgery. This study aimed to compare the safety and best use of the distal locking screw in 170 mm PFNA and 240 mm PFNA devices, and to determine the safe region for placement of the distal locking screw in PFNA surgery. Material/Methods A retrospective analysis of 100 patients with 170 mm PFNA and 80 patients with 240 mm PFNA were retrospectively analyzed. Two levels of PFNA distal locking screws were equally divided into three planes: I, II, III, for 170 mm PFNA devices and i, ii, iii for the 240 mm PRNA devices. The medial half of the femur was equally divided into eight regions: A to H. The distance between the outer femur and the superficial, the deep and the perforating femoral arteries (SFAs, DFAs, and PFAs), and angles between the reference line and the connection line between the femur center to each artery were measured. Results SFAs and DFAs but not PFAs were found in risky or hazardous regions, and DFAs were obviously closer to the femur than SFAs and PFAs at the same level. In the region within 10 mm of the femur, no SFAs were found. The short nails (170 mm PFNA-II devices) were the closest to the DFAs region, indicating that the 170 mm PFNA-II nails are most likely to cause special vessel injury. The short nails were relatively more distant from the SFAs, which were located posteriorly to the long nails (240 mm PFNA-II). Conclusions The distal locking screw of the 170 mm PFNA device was more prone to damage the femoral deep artery when the two types of PFNA devices are compared in patients who were candidates for both types of devices. PMID:28178228
Rethnam, Ulfin; Cordell-Smith, James; Kumar, Thirumoolanathan M; Sinha, Amit
Background Unstable proximal femoral fractures and pathological lesions involving the trochanteric region in the elderly comprise an increasing workload for the trauma surgeon as the ageing population increases. This study aims to evaluate use of the Russell-Taylor reconstruction nail (RTRN) in this group with regard to mortality risk, complication rates and final outcome. Methods Retrospective evaluation of 42 patients aged over 60 years who were treated by reconstruction nailing for proximal femoral fractures over a 4 year period. Results Over two-thirds of patients were high anaesthetic risk (ASA > 3) with ischemic heart disease the most common co-morbidity. 4 patients died within 30 days of surgery and 4 patients required further surgery for implant related failure. Majority of patients failed to regain their pre-injury mobility status and fewer than half the patients returned to their original domestic residence. Conclusion Favourable fixation of unstable complex femoral fractures in the elderly population can be achieved with the Russell-Taylor reconstruction nail. However, use of this device in this frail population was associated with a high implant complication and mortality rate that undoubtedly reflected the severity of the injury sustained, co-morbidity within the group and the stress of a major surgical procedure. PMID:18271998
Song, Kyung Sub; Lee, Su Keon; Lee, Seung Hwan; Yang, Bong Seok; Park, Byeong Mun; Yang, Ick Hwan; Lee, Beom Seok; Yeom, Ji Ung
Purpose Hip fractures in hemodialysis patients are accompanied by high rates of complications and morbidities. Previous studies have mainly reported on nonunion and avascular necrosis of femoral neck fractures in this patient group. In this study the complication and clinical results of hemodialysis patients with intertrochanteric fractures treated with proximal femoral intramedullary nailing have been investigated through comparison with patients with normal kidney function. Materials and Methods Forty-seven patients were included; the hemodialysis group (n=17) and the control group with normal kidney function (n=30). The medical history and clinical findings including preoperative and postoperative blood examinations, radiological examinations and ambulatory status (measured using the Koval score). The rate of complications and morbidities were also investigated and compared. Results Preoperative hemoglobin/hematocrit was lower but a significant increase in partial thromboplastin time was observed in the hemodialysis group. The amount of bleeding/transfusions were higher and operative time was longer in the hemodialysis group. Upon radiologic examination, there was no significant difference in rate of unstable fracture and nonunion between the two groups. However the postoperative Koval score was significantly worse and the odds ratio of inability to walk after surgery was 13.5 times higher in the hemodialysis group. Conclusion There was no significant difference in radiological results, but the risk of inability to walk after surgery was 13.5 times higher in the hemodialysis group. Hemodialysis patients have more morbidities and are hemodynamically unstable therefore require special attention. Accurate reduction and firm fixation is required and attentive postoperative rehabilitation is needed. PMID:28316963
Yu, Weiguang; Zhang, Xinchao; Zhu, Xingfei; Hu, Jun; Liu, Yunjiang
The purpose of this study was to compare the clinical outcomes of elderly patients undergoing surgery for treatment of unstable trochanteric fractures receiving either proximal femoral nails anti-rotation-Asia (PFNA-IIs) or InterTan nails (ITs). Between January 1, 2012, and June 31, 2015, 168 elderly patients with unstable intertrochanteric femur fractures enrolled in this study. The only intervention was ITs or PFNA-IIs of the unstable trochanteric femur fractures. Follow-up was at 1, 3, 6, and 12 months postoperatively and yearly thereafter. Intraoperative variables and postoperative complications were compared between the two groups. Eight patients died, six were too infirmed for follow-up, and seven were lost during follow-up, leaving 147 patients meeting the criteria were evaluated at a mean follow-up of 20 months (range 16-26 months). Significant differences were observed between the two groups regarding local complications (IT, n = 10 vs. PFNA-II, n = 20), varus collapse of the head/neck or femoral shaft fractures at the tip of the nail (IT, n = 1 vs. PFNA-II, n = 8), femoral neck shortening (IT, 4.4 ± 1.1 mm vs. PFNA-II, 7.4 ± 2.4 mm), fracture healing time (IT, 14.7 ± 2.1 weeks vs. PFNA-II, 15.7 ± 2.4 weeks), femoral shaft fractures (IT, n = 0 vs. PFNA-II, n = 4), rotational loss of reduction (IT, n = 0 vs. PFNA-II, n = 9), lateral cortex fractures of the proximal femur or lateral greater trochanter fractures (IT, n = 8 vs. PFNA-II, n = 1), operative time (IT, 71.9 ± 6.8 min vs. PFNA-II, 52.3 ± 4.0 min), intraoperative blood loss (IT, 190.6 ± 6.0 mL vs. PFNA-II, 180.9 ± 10.8 mL), fluoroscopy time (IT, 5.0 ± 0.48 min vs. PFNA-II, 2.8 ± 0.33 min), hospital stay (IT, 9.65 ± 0.95 days vs. PFNA-II, 8.58 ± 0.93 days), cut-out (IT, n = 0 vs. PFNA-II, n = 6), and tip-apex distance (IT, 26.7 ± 0.91 mm vs. PFNA-II, 23.2 ± 1.22 mm). No significant differences existed for the other observation indexes (p > 0.05). The IT nail may have more advantage for
Clark, Amanda; Hilt, J Zach; Milbrandt, Todd A; Puleo, David A
Growth plate fractures account for nearly 18.5% of fractures in children. Depending on the type and severity of the injury, inhibited bone growth or angular deformity caused by bone forming in place of the growth plate can occur. The current treatment involves removal of the bony bar and replacing it with a filler substance, such as a free fat graft. Unfortunately, reformation of the bony bar frequently occurs, preventing the native growth plate from regenerating. The goal of this pilot study was to determine whether biodegradable scaffolds can enhance native growth plate regeneration following a simulated injury that resulted in bony bar formation in the proximal tibial growth plate of New Zealand white rabbits. After removing the bony bar, animals received one of the following treatments: porous poly(lactic-co-glycolic acid) (PLGA) scaffold; PLGA scaffold loaded with insulin-like growth factor I (IGF-I); PLGA scaffold loaded with IGF-I and seeded with autogenous bone marrow cells (BMCs) harvested at the time of implantation; or fat graft (as used clinically). The PLGA scaffold group showed an increased chondrocyte population and a reduced loss of the remaining native growth plate compared to the fat graft group (the control group). An additional increase in chondrocyte density was seen in scaffolds loaded with IGF-I, and even more so when BMCs were seeded on the scaffold. While there was no significant reduction in the angular deformation of the limbs, the PLGA scaffolds increased the amount of cartilage and reduced the amount of bony bar reformation.
Clark, Amanda; Hilt, J. Zach; Milbrandt, Todd A.; Puleo, David A.
Abstract Growth plate fractures account for nearly 18.5% of fractures in children. Depending on the type and severity of the injury, inhibited bone growth or angular deformity caused by bone forming in place of the growth plate can occur. The current treatment involves removal of the bony bar and replacing it with a filler substance, such as a free fat graft. Unfortunately, reformation of the bony bar frequently occurs, preventing the native growth plate from regenerating. The goal of this pilot study was to determine whether biodegradable scaffolds can enhance native growth plate regeneration following a simulated injury that resulted in bony bar formation in the proximal tibial growth plate of New Zealand white rabbits. After removing the bony bar, animals received one of the following treatments: porous poly(lactic-co-glycolic acid) (PLGA) scaffold; PLGA scaffold loaded with insulin-like growth factor I (IGF-I); PLGA scaffold loaded with IGF-I and seeded with autogenous bone marrow cells (BMCs) harvested at the time of implantation; or fat graft (as used clinically). The PLGA scaffold group showed an increased chondrocyte population and a reduced loss of the remaining native growth plate compared to the fat graft group (the control group). An additional increase in chondrocyte density was seen in scaffolds loaded with IGF-I, and even more so when BMCs were seeded on the scaffold. While there was no significant reduction in the angular deformation of the limbs, the PLGA scaffolds increased the amount of cartilage and reduced the amount of bony bar reformation. PMID:26309783
Koyuncu, Şemmi; Altay, Taşkın; Kayalı, Cemil; Ozan, Fırat; Yamak, Kamil
This study aims at assessing the clinical results, radiographic findings, and associated complications after osteosynthesis of trochanteric hip fractures with proximal femoral nail (PFN). A total of 152 patients with hip fractures who underwent osteosynthesis with PFN were included. The hip fracture types in the patients included in the study were classified according to the American Orthopedic/Orthopedic Trauma Association (AO/OTA). AO/OTA A1, A2, and A3 type fractures were found in 24 (15.8%), 107 (70.4%), and 21 (13.8%) patients, respectively. The Baumgaertner scale was used to assess the degree of postoperative reduction. The Salvati-Wilson hip function (SWS) scoring system was used to evaluate functional results. After a follow-up period, clinical and radiographic results were evaluated and complications were assessed. The relationship between the complications and SWS score, age, sex, fracture type, reduction quality, and time from the fracture to surgery was evaluated. Eighty-five (55.9%) female patients and 67 (44.1%) male patients were enrolled in the study. Seventy-nine (51.9%) patients had left hip fractures, and 73 (48.1%) had right hip fractures. The mean age was 76 (range 21-93) years, and the mean follow-up duration was 23.6 (range 7-49) months. Postoperatively, one patient (0.6%) had a poor reduction, 16 patients (10.5%) had an acceptable reduction, and 135 patients (88.9%) had a good reduction according to the above criteria. The SWS scores were excellent, good, moderate, and poor in 91 (59.8%), 45 (29.6%), 15 (9.8%), and one (0.6%) patients, respectively. Late postoperative complications were seen in 27 patients (17.7%). A total of 14 patients (9.2%) underwent a revision procedure for mechanical complications. The study results suggest that the quality of fracture reduction is an important factor that affects the revision rate and SWS score in patients with mechanical complications after osteosynthesis with PFN for trochanteric fractures.
Background The most common mechanical failure in the internal fixation of trochanteric hip fractures is the cut-out of the sliding screw through the femoral head. Several factors that influence this complication have been suggested, but there is no consensus as to the relative importance of each factor. The purpose of this study was to analyse the cut-out complication with respect to the following variables: patients’ age, fracture type, fracture reduction, implant positioning and implant design. Methods 3066 consecutive patients were treated for trochanteric fractures with Gamma Nails between 1990 and 2002 at the Centre de Traumatologie et de l`Orthopedie (CTO), Strasbourg, France. Cut-out complications were identified by reviewing all available case notes and radiographs. Subsequently, the data were analysed by a single reviewer (AJB) with focus on the studied factors. Results Seventy-one cut-out complications were found (2.3%) of the 3066 trochanteric fractures. Cut-out failure associated with avascular head necrosis, pathologic fracture, deep infection or secondary to prior failure of other implants were excluded from the study (14 cases). The remaining 57 cases (1.85 %, median age 82.6, 79% females) were believed to have a biomechanical explanation for the cut-out failure. 41 patients had a basicervical or complex fracture type. A majority of cut-outs (43 hips, 75%) had a combination of the critical factors studied; non-anatomical reduction, non-optimal lag screw position and the characteristic fracture pattern found. Conclusions The primary cut-out rate of 1.85% was low compared with the literature. A typical cut-out complication in our study is represented by an unstable fracture involving the trochanteric and cervical regions or the combination of both, non-anatomical reduction and non-optimal screw position. Surgeons confronted with proximal femoral fractures should carefully scrutinize preoperative radiographs to assess the primary fracture geometry and
Lin, Chun-Cheng; Chen, Chuan-Mu; Chiu, Fang-Yao; Su, Yu-Pin; Liu, Chien-Lin; Chen, Tain-Hsiung
Open tibial shaft fractures are the most common open fractures, and many complications can occur. During the treatment period, infection leading to osteomyelitis was the most common complication. However, no consensus exists regarding the ideal management for such cases in the literature.The purposes of this retrospective study were to review the treatment of patients with chronic tibial shaft osteomyelitis over the past 14 years who were referred to the authors' institution and to provide a staged protocol for spontaneous wound healing. The staged protocol included: (1) radical debridement for infected bone and soft tissue; (2) immediate application of Ilizarov's apparatus for all patients except those needing delayed application; (3) osteotomy in healthy bone; (4) simultaneous distraction-compression osteogenesis and histogenesis; (5) additional docking-site bone grafting; and (6) shifting the external fixator to a locked nail when callus formation was visible at the distraction site. Union was achieved in 15 of 16 patients, with an average external fixation time of 4.5 months (range, 3-6 months). No deformity or leg-length discrepancy greater than 1 cm occurred.In the treatment of chronic osteomyelitis, this staged protocol was safe and successful and allowed for union, realignment, reorientation, and leg-length restoration. Regarding the soft tissues, this technique provides a unique type of reconstructive closure for infected wounds. It is suggested that the staged protocol is reliable in providing successful simultaneous reconstruction for bone and soft tissue defects without flap coverage.
Yaozeng, Xu; Dechun, Geng; Huilin, Yang; Guangming, Zhu; Xianbin, Wang
To compare the results between the proximal femoral nail anti-rotation (PFNA) and the third generation gamma nail (TGN) in the treatment of trochanteric fractures. Between April 2007 and May 2008, 107 consecutive patients older than 60 years with trochanteric femoral fractures were treated with PFNA or TGN. The preoperative variables including patient age, gender, fracture classification, walking ability and American Society of Anaesthesiologists (ASA) rating of operative risk were summarised. Operative time, fluoroscopy time, blood loss, and any intra-operative complication were recorded for each patient. Follow-up was undertaken at 3, 6, and 12 postoperative months, and yearly thereafter. Plain AP and lateral radiographs were obtained at all visits. All changes in the position of the implant, complications, or fixation failure were recorded. Hip range of motion, pain about the hip and the thigh, walking ability score and return to work status were used to compare the outcomes. There were 55 patients in the PFNA group and 52 in the TGN group. The two groups were comparable with regard to the preoperative variables. The mean follow-up time was 17.5 months (range 12–24). Patients treated with a PFNA experienced a shorter fluoroscopy time and less blood loss. Sixteen patients were lost during the follow-up period. All the other fractures were radiographically healed at the last visit. There were no significant differences between the groups in terms of functional outcomes, hospital stay, intra-operative and postoperative complications. PFNA provides less blood loss and shorter fluoroscopy time but no advantages in functional outcome, intra-operative and postoperative complications when compared with TGN. These two implants were comparable in the treatment of trochanteric fractures.
Yoon, Han Kook; Park, Junyoung; Oyunbat, Choidog; Kim, Taehwan
Recently, we experienced a case where the diagnosis and management of a deep femoral artery rupture was delayed. This vascular complication occurred during the insertion of a distal interlocking screw of a proximal femoral nail for the fixation of an intertrochanteric femur fracture. A 79-year-old male patient was diagnosed with a right intertrochanteric fracture after a fall. We fixed the fracture with a proximal femoral nail (Zimmer® Natural Nail™ System). One day after the procedure, the patient complained of pain and swelling on the anteromedial side of his middle thigh followed by hypotension, anemia and prolonged thigh swelling. Computed tomography angiography was performed 7 days after the procedure. We found a pseudoaneurysm of the perforating artery caused by injury to the deep femoral artery and an intramuscular hematoma in the anterior thigh muscle. We successfully treated the pseudoaneurysm using coil embolization. Throughout the management of intertrochanteric femoral fractures, it is important to be aware and monitor signs and symptoms related to the possibility of blood vessel damage. When a patient presents with swelling and pain on the middle thigh and/or unexplained anemia postoperatively, the possibility that these symptoms are caused by an injury to the femoral artery must be considered. PMID:27536645
Yokoyama, Kazuhiko; Itoman, Moritoshi; Uchino, Masataka; Fukushima, Kensuke; Nitta, Hiroshi; Kojima, Yoshiaki
Background: The purpose of this study was to evaluate contributing factors affecting deep infection and fracture healing of open tibia fractures treated with locked intramedullary nailing (IMN) by multivariate analysis. Materials and Methods: We examined 99 open tibial fractures (98 patients) treated with immediate or delayed locked IMN in static fashion from 1991 to 2002. Multivariate analyses following univariate analyses were derived to determine predictors of deep infection, nonunion, and healing time to union. The following predictive variables of deep infection were selected for analysis: age, sex, Gustilo type, fracture grade by AO type, fracture location, timing or method of IMN, reamed or unreamed nailing, debridement time (≤6 h or >6 h), method of soft-tissue management, skin closure time (≤1 week or >1 week), existence of polytrauma (ISS< 18 or ISS≥18), existence of floating knee injury, and existence of superficial/pin site infection. The predictive variables of nonunion selected for analysis was the same as those for deep infection, with the addition of deep infection for exchange of pin site infection. The predictive variables of union time selected for analysis was the same as those for nonunion, excluding of location, debridement time, and existence of floating knee and superficial infection. Results: Six (6.1%; type II Gustilo n=1, type IIIB Gustilo n=5) of the 99 open tibial fractures developed deep infections. Multivariate analysis revealed that timing or method of IMN, debridement time, method of soft-tissue management, and existence of superficial or pin site infection significantly correlated with the occurrence of deep infection (P< 0.0001). In the immediate nailing group alone, the deep infection rate in type IIIB + IIIC was significantly higher than those in type I + II and IIIA (P = 0.016). Nonunion occurred in 17 fractures (20.3%, 17/84). Multivariate analysis revealed that Gustilo type, skin closure time, and existence of deep
Chen, Chun-Ming; Chen, Pai-Li; Wu, Chung-Wei; Huang, I-Yueh; Lee, Kun-Tsung
Maxillary sinus enlargement often occurs in the maxillary posterior edentulous area and reduces the available bone height for implantation. Therefore, maxillary sinus lift and bone graft procedures are necessary to provide sufficient available bone. Autogenous bone grafting is the best base for implant osseointegration. Recently, tibial bone has been recognized as an alternative extraoral donor site. We present a case in which we used a proximal tibia bone graft for maxillary sinus augmentation under local anesthesia without sedation in the dental office. During a 4-year postoperative follow-up, gait was not disturbed and the scar on the donor site remained unremarkable.
Havet, Eric; Gabrion, Antoine; Leiber-Wackenheim, Frederic; Vernois, Joël; Olory, Bruno; Mertl, Patrice
Restoring the joint line level is one of the surgical challenges during revision of total knee arthroplasty. The position of the tibial surface is commonly estimated by its distance to the apex of fibular head, but no study evaluating this distance accurately has been published yet. The purpose of this work was to study the distance between the knee joint line and the apex of the fibular head and the proximal tibia, particularly the tibial tuberosity. Variability with clinical data and relations with other local measurements have been evaluated on knee radiographs (an antero-posterior view, a medio-lateral view and an anteroposterior full length view) of 100 subjects (125 knees). Results showed no correlation between the joint line-fibular head apex distance and any clinical data of the patients, or any other performed measurements. Relations between tibial measurements and the sexe or the height of the subjects were noted. Besides, the review of the 25 bilateral cases did not show statistically significant side difference but the descriptive analysis showed too large discrepancies for the joint line-fibular head apex distance to be used as a landmark. We conclude that the fibular head apex cannot be used as a morphologic landmark to determine the knee joint line position. Its interest in clinical and surgical practice must be discussed.
Scott, C E H; Eaton, M J; Nutton, R W; Wade, F A; Evans, S L; Pankaj, P
Up to 40% of unicompartmental knee arthroplasty (UKA) revisions are performed for unexplained pain which may be caused by elevated proximal tibial bone strain. This study investigates the effect of tibial component metal backing and polyethylene thickness on bone strain in a cemented fixed-bearing medial UKA using a finite element model (FEM) validated experimentally by digital image correlation (DIC) and acoustic emission (AE). A total of ten composite tibias implanted with all-polyethylene (AP) and metal-backed (MB) tibial components were loaded to 2500 N. Cortical strain was measured using DIC and cancellous microdamage using AE. FEMs were created and validated and polyethylene thickness varied from 6 mm to 10 mm. The volume of cancellous bone exposed to < -3000 µε (pathological loading) and < -7000 µε (yield point) minimum principal (compressive) microstrain and > 3000 µε and > 7000 µε maximum principal (tensile) microstrain was computed. Experimental AE data and the FEM volume of cancellous bone with compressive strain < -3000 µε correlated strongly: R = 0.947, R(2) = 0.847, percentage error 12.5% (p < 0.001). DIC and FEM data correlated: R = 0.838, R(2) = 0.702, percentage error 4.5% (p < 0.001). FEM strain patterns included MB lateral edge concentrations; AP concentrations at keel, peg and at the region of load application. Cancellous strains were higher in AP implants at all loads: 2.2- (10 mm) to 3.2-times (6 mm) the volume of cancellous bone compressively strained < -7000 µε. AP tibial components display greater volumes of pathologically overstrained cancellous bone than MB implants of the same geometry. Increasing AP thickness does not overcome these pathological forces and comes at the cost of greater bone resection.Cite this article: C. E. H. Scott, M. J. Eaton, R. W. Nutton, F. A. Wade, S. L. Evans, P. Pankaj. Metal-backed versus all-polyethylene unicompartmental knee arthroplasty: Proximal tibial strain in an experimentally validated
Petrigliano, Frank A; Suero, Eduardo M; Voos, James E; Pearle, Andrew D; Allen, Answorth A
Proximal tibial slope has been shown to influence anteroposterior translation and tibial resting point in the posterior cruciate ligament (PCL)-deficient knee. The effect of proximal tibial slope on rotational stability of the knee is unknown. Change in proximal tibial slope produced via osteotomy can influence both static translation and dynamic rotational kinematics in the PCL/posterolateral corner (PLC)-deficient knee. Controlled laboratory study. Posterior drawer, dial, and mechanized reverse pivot-shift (RPS) tests were performed on hip-to-toe specimens and translation of the lateral and medial compartments measured utilizing navigation (n = 10). The PCL and structures of the PLC were then sectioned. Stability testing was repeated, and compartmental translation was recorded. A proximal tibial osteotomy in the sagittal plane was then performed achieving either +5° or -5° of tibial slope variation, after which stability testing was repeated (n = 10). Analysis was performed using 1-way analysis of variance (ANOVA; α = .05). Combined sectioning of the PCL and PLC structures resulted in a 10.5-mm increase in the posterior drawer, 15.5-mm increase in the dial test at 30°, 14.5-mm increase in the dial test at 90°, and 17.9-mm increase in the RPS (vs intact; P < .05). Increasing the posterior slope (high tibial osteotomy [HTO] +5°) in the PCL/PLC-deficient knee reduced medial compartment translation by 3.3 mm during posterior drawer (vs deficient; P < .05) but had no significant effect on the dial test at 30°, dial test at 90°, or RPS. Conversely, reversing the slope (HTO -5°) caused a 4.8-mm increase in medial compartment translation (vs deficient state; P < .05) during posterior drawer and an 8.6-mm increase in lateral compartment translation and 9.0-mm increase in medial compartment translation during RPS (vs deficient state; P < .05). Increasing posterior tibial slope diminished static posterior instability of the PCL/PLC-deficient knee as measured by the
Chandraprakasam, Thangavel; Thambiraj, Sathya
Background Proximal phalangeal fractures are common fractures of the hand. The fractures are difficult to treat because of vicinity of two important joints and crossing long tendons. The purpose of this study was to evaluate the efficacy of nail traction technique in the management of proximal phalangeal fractures of the hand. Methods Patients (n=43) with proximal phalangeal fractures were treated by nail traction and evaluated prospectively. We assessed all the patients at the time of presentation and then followed a standard protocol for recruiting patients. After application of nail traction, the patients were initially assessed at 12th day. The outcome measures included post reduction radiographic evaluation and total active motion (TAM) in finger at the final follow-up appointment. All the patients were followed for one year. Results The post-reduction X-ray evaluation showed good reduction in 33 cases, fair reduction in 8 and poor reduction in 2 cases. At final assessment, 35 patients had good TAM score, six had fair and two had poor TAM score. Complications were noted in two patients and these included pressure necrosis in palm and stiffness in proximal interphalangeal joint. Conclusions The results of this prospective study show that with careful selection of patients, nail traction seems to be simple, safe and effective technique for managing proximal phalangeal fractures. PMID:22662302
There is a growing imperative to understand how changes in peri-articular bone relate to pathological progression of knee osteoarthritis (KOA). Peri-articular bone density can be measured using dual x-ray absorptiometry (DXA). The medial:lateral tibial BMD ratio (M:L BMD) is associated with MRI and...
Wang, Haosen; Hao, Zhixiu; Wen, Shizhu
Intramedullary interlocking nailing is an effective technique used to treat long bone fractures. Recently, biodegradable metals have drawn increased attention as an intramedullary interlocking nailing material. In this study, numerical simulations were implemented to determine whether the degradation rate of magnesium alloy makes it a suitable material for manufacturing biodegradable intramedullary interlocking nails. Mechano-regulatory and bone-remodeling models were used to simulate the fracture healing process, and a surface corrosion model was used to simulate intramedullary rod degradation. The results showed that magnesium alloy intramedullary rods exhibited a satisfactory degradation rate; the fracture healed and callus enhancement was observed before complete dissolution of the intramedullary rod. Delayed magnesium degradation (using surface coating techniques) did not confer a significant advantage over the non-delayed degradation process; immediate degradation also achieved satisfactory healing outcomes. However, delayed degradation had no negative effect on callus enhancement, as it did not cause signs of stress shielding. To avoid risks of individual differences such as delayed union, delayed degradation is recommended. Although the magnesium intramedullary rod did not demonstrate rapid degradation, its ability to provide high fixation stiffness to achieve earlier load bearing was inferior to that of the conventional titanium alloy and stainless steel rods. Therefore, light physiological loads should be ensured during the early stages of healing to achieve bony healing; otherwise, with increased loading and degraded intramedullary rods, the fracture may ultimately fail to heal.
Pogorelić, Z; Kadić, S; Milunović, K P; Pintarić, I; Jukić, M; Furlan, D
The aim of this study was to analyze outcomes of treatment and complications in children treated with flexible intramedullary nailing (FIN) due to humeral fracture. The FIN for treatment of humeral fractures in children would allow an early functional and cast-free follow-up with a quick pain reduction and low complication rate. From May 2002 until May 2016 case records of all children who underwent fixation with titanium intramedullary nails because of humeral fracture were retrospectively reviewed. The study included 118 patients treated with FIN for proximal humeral or humeral shaft fracture. The average age at the time of trauma was 12 years. Mean follow-up was 77 months. Left hand was affected in 51% of patients. The most common mechanism of injury was fall (n=58), followed by sports injuries, road traffic accidents, pathological fractures, motorbike accidents and bicycle riding. There were no residual valgus/varum deformities. All patients achieved complete radiographic healing at a mean of 7.5 weeks. Nine complications were recorded: 1 humeral shaft fracture in patient with osteogenesis imperfecta, 4 entry site skin irritations, 2 skin infections and 2 radial nerve injuries. There were no cases of delayed union, nonunion or mal-union. After removal of the nails, all patients regained full function and all complications resolved. The FIN for humeral fractures is a minimally invasive, simple and well reproducible technique with very low complication rate. The FIN for treatment of humeral fractures shows very good functional and cosmetic results. It allows an early functional and cast-free follow-up with a quick pain reduction. Level IV - retrospective study. Copyright © 2017 Elsevier Masson SAS. All rights reserved.
Turgut, Ali; Kalenderer, Önder; Günaydın, Burak; Önvural, Burak; Karapınar, Levent; Ağuş, Haluk
The aim of this study was to evaluate whether intertrochanteric femur fractures can be reduced and nailed properly in the lateral decubitus position using Proximal Femoral Nail Antirotation (PFNA) as a fixation device without the use of a traction table. The study included 207 patients (81 male and 126 female; mean age: 75 years, range: 22 to 95 years). According to the Evans classification, there were 7 Type 1, 40 Type 2, 33 Type 3, 38 Type 4, 61 Type 5 and 28 reverse oblique fractures. Radiographs were used to measure the tip-apex distance (TAD), the quadrant of the helical blade according to Cleveland and Bosworth, Ikuta's reduction subgroup, collodiaphyseal angle and reduction gaps postoperatively. Mean follow-up time was 20.4 (range: 6 to 38) months. According to Ikuta's classification, 176 (85%) reduced fractures were of subtype N, 15 (7.2%) subtype P and 16 (7.7%) subtype A. Good or acceptable reduction according to the Herman criteria was obtained in 99% of fractures. Mean TAD was 29.2 millimeters. Mean operation time was 57.2 minutes. Optimal blade position (center-center or inferior-center) was achieved in 53.5% of patients and was in the superior-posterior quadrants in only 2.4% of patients. Cut-out complication occurred in 9 patients (4.3%). While the nailing of intertrochanteric fractures in a lateral decubitus position does not provide ideal quadrant placement and TAD, results are encouraging probably due to the excellent stability that is provided by PFNA.
Chen, Liang-Chin; Chan, Yi-Sheng; Wang, Ching-Jen
Injuries to the proximal tibial physis are among the least common epiphyseal injuries. We present a case of severe genu recurvatum deformity (45 degrees) with leg length discrepancy (4 cm) following a neglected proximal tibial physeal injury incurred 6 years previously. The 16-year-old patient was successfully treated by open-wedge osteotomy, allograft reconstruction, and dual buttress plate fixation. At 3 years' follow-up, the patient was asymptomatic, fully active with a full range of motion (0 - 140 degrees) of the leg, and equal leg lengths. There were no signs of genu recurvatum clinically.
Forman, Jordanna M; Urruela, Adriana M; Egol, Kenneth A
The purpose of this retrospective chart and radiographic review is to describe an effective reduction technique during intramedullary nailing of distal metaphyseal tibia fractures with the use of a pointed percutaneous clamp. Between 2007 and 2010, 100 patients who sustained 102 tibia fractures were definitively treated with an intramedullary nail at one of two medical centers. Diaphyseal fractures and injuries with an associated disruption of the distal tibiofibular joint were excluded from our study. A total of 27 patients with 27 distal metaphyseal tibia fractures (OTA types 42-A, 43-A, and 43-B) were included. All 27 patients underwent IM nailing of their fractures with anatomic reduction achieved using a percutaneously placed pointed reduction clamp prior to insertion of the IM implant. Fracture alignment and angular deformity was assessed using goniometric measurement functions on the PACS system (GE, Waukeshau, WI) obtained from preoperative and postoperative anteroposterior and lateral images for all subjects. Malalignment was defined as more than 5 degrees of angulation in any plane. Fourteen of the fractures were classified as OTA 42-A, 9 were OTA 43-A, and 4 were OTA 43-B. Analysis of post-closed reduction, preoperative anteroposterior radiographs revealed a mean of 7.9 degrees of coronal plane (range: 0.9 degrees-26 degrees) angulation. Post closed reduction preoperative lateral radiographs revealed a mean of 6.8 degrees sagittal plane (range: 0 degrees-24.6 degrees) angulation. Postoperative anteroposterior and lateral radiographs showed the distal segment returned to its anatomical alignment with a mean angulation of 0.5 degrees (range, 0 degrees-3.5 degrees) and 0.7 degrees (range, 0 degrees-4.2 degrees) of varus/ valgus and apex anterior/posterior angulation, respectively. These results showed an acceptable postopertative alignment in all 27 distal third fractures. No intra-operative or postoperative complications were noted in the study group. This
Ma, Y. F.; Jee, W. S.; Ke, H. Z.; Lin, B. Y.; Liang, X. G.; Li, M.; Yamamoto, N.
The purpose of this study was to determine if human parathyroid hormone-(1-38) (hPTH(1-38)) can restore cancellous bone mass to the established osteopenic, immobilized proximal tibial metaphyses of female rats. The right hindlimbs of 6-month-old female Sprague-Dawley rats were immobilized by bandaging the right hindlimbs to the abdomen. After 30 days of right hindlimb immobilization, the rats were subcutaneously injected with 200 micrograms hPTH(1-38)/kg/day for 15 days (short-term treatment) or 75 days (longer-term treatment). Static bone histomorphometry was performed on the primary spongiosa, and both static and dynamic histomorphometry were performed on the secondary spongiosa of the right proximal tibial metaphyses. Immobilization for 30 days without treatment decreased trabecular bone area, number, and thickness in both primary and secondary spongiosa, and induced an increase in eroded perimeter and a decrease in tissue referent-bone formation rate in the secondary spongiosa. These changes reached a new steady state thereafter. Treatment with 200 micrograms hPTH(1-38)/kg/day for 15 days, beginning 30 days after immobilization, significantly increased trabecular bone area, thickness, and number in both primary and secondary spongiosa despite continuous immobilization when compared with controls. The short-term PTH treatment (15 days) significantly increased labeling perimeter, mineral apposition rate, and tissue referent-bone formation rate in the secondary spongiosa and stimulated longitudinal bone growth as compared with the controls. Longer PTH treatment (75 days) further increased trabecular bone area, thickness, and number as compared with controls and groups given short-term PTH treatment (15 days). The bone formation indices in the secondary spongiosa of the longer-term treated rats were lower than those of the short-term treated group, but they were still higher than those of controls. Our findings indicate that PTH treatment stimulates cancellous bone
Ma, Y. F.; Jee, W. S.; Ke, H. Z.; Lin, B. Y.; Liang, X. G.; Li, M.; Yamamoto, N.
The purpose of this study was to determine if human parathyroid hormone-(1-38) (hPTH(1-38)) can restore cancellous bone mass to the established osteopenic, immobilized proximal tibial metaphyses of female rats. The right hindlimbs of 6-month-old female Sprague-Dawley rats were immobilized by bandaging the right hindlimbs to the abdomen. After 30 days of right hindlimb immobilization, the rats were subcutaneously injected with 200 micrograms hPTH(1-38)/kg/day for 15 days (short-term treatment) or 75 days (longer-term treatment). Static bone histomorphometry was performed on the primary spongiosa, and both static and dynamic histomorphometry were performed on the secondary spongiosa of the right proximal tibial metaphyses. Immobilization for 30 days without treatment decreased trabecular bone area, number, and thickness in both primary and secondary spongiosa, and induced an increase in eroded perimeter and a decrease in tissue referent-bone formation rate in the secondary spongiosa. These changes reached a new steady state thereafter. Treatment with 200 micrograms hPTH(1-38)/kg/day for 15 days, beginning 30 days after immobilization, significantly increased trabecular bone area, thickness, and number in both primary and secondary spongiosa despite continuous immobilization when compared with controls. The short-term PTH treatment (15 days) significantly increased labeling perimeter, mineral apposition rate, and tissue referent-bone formation rate in the secondary spongiosa and stimulated longitudinal bone growth as compared with the controls. Longer PTH treatment (75 days) further increased trabecular bone area, thickness, and number as compared with controls and groups given short-term PTH treatment (15 days). The bone formation indices in the secondary spongiosa of the longer-term treated rats were lower than those of the short-term treated group, but they were still higher than those of controls. Our findings indicate that PTH treatment stimulates cancellous bone
Takano, Marcelo Itiro; de Moraes, Ramon Candeloro Pedroso; de Almeida, Luis Gustavo Morato Pinto; Queiroz, Roberto Dantas
Objective To analyze the influence of femoral neck diameter in the positioning of the sliding screw in cefalomedulares nails for treatment of unstable transtrochanteric fractures. Methods Prospectively throughout 2011, patients with unstable fractures transtrochanteric undergoing osteosynthesis with cephalomedullary nail using antirotacional device. They were evaluated for sex, age and fracture classification according to Tronzo. Through digital radiographs angle reduction, tip apex distance (TAD), stem diameter and measures between the positioning of the screws and the limits of the cervix were measured. Results Of the 58 patients, 42 (72.4%) were female and 16 (27.6%) were male. 33 patients were classified as Tronzo III (56.9%), 6 patients as Tronzo IV (10.4%) and 19 as Tronzo V (19.8%). The majority were in between the eighth and ninth decade of life. The average reduction in the angle was 130.05° for females and 129.4° for males. The TAD average was 19.7 mm for females and 21.6 for males. The average diameter of the neck and head vary with statistical significance between men and women. In 19 patients the placement of the sliding bolt can be optimal. If the ideal positioning was not possible, the mean displacement for non‐infringement of higher cortical neck was 4.06 mm. Conclusion The optimal placement would not be possible for the majority of the population, for the average diameter of the neck of the sample. PMID:26229767
Metaphyseal screw augmentation of the LISS-PLT plate with polymethylmethacrylate improves angular stability in osteoporotic proximal third tibial fractures: a biomechanical study in human cadaveric tibiae.
Goetzen, Michael; Nicolino, Tomas; Hofmann-Fliri, Ladina; Blauth, Michael; Windolf, Markus
The incidence of osteoporotic proximal tibial fractures has increased during the last 2 decades. A promising approach in osteoporotic fracture fixation is polymethylmethacrylate-based cement augmentation of implants to gain better implant purchase in the bone. This study investigates the biomechanical benefits of screw augmentation in less invasive stabilization system-proximal lateral tibial (LISS-PLT) plates in cadaveric extraarticular comminuted proximal tibial fractures (OTA-41-A3.3). Standardized extraarticular proximal tibial fractures were stabilized with the LISS-PLT plate in 6 paired osteoporotic cadaveric tibiae. Bone mineral density was measured with high-resolution, quantitative computed tomography scans to identify bone quality. In the augmented group, the 5 proximal screws of the LISS-PLT plate were augmented with 1 mL of bone cement each, whereas the contralateral tibia was instrumented conventionally as the control. Cyclic axial loading was applied to each specimen with a starting load of 150 N, using a ramp of 0.05 N per cycle to 10-mm axial displacement. Varus displacement was identified from anterior-posterior radiographs. Bone mineral density showed no significant difference between the 2 groups (P = 0.47). The nonaugmented group reached 9417 load cycles (SD 753) until failure, compared with 14,792 load cycles (SD 2088) in the augmented group (P = 0.002). In the early-onset failure (deformation at 8250 load cycles), varus displacement was significantly smaller in the augmented group (0.46 degrees, SD 0.6) than in the nonaugmented group (3.23 degrees, SD 1.7) (P = 0.01). This biomechanical study showed that cement augmentation of the LISS-PLT plate screws in osteoporotic proximal extraarticular tibial fractures significantly lowers the propensity toward screw migration and secondary varus displacement.
da Cunha Luciano, Roberto; de Moura Souza, Getúlio Danival; Rispoli, Juliano; Cardoso, Rodrigo Galvão; do Nascimento, Marcus Vinícius Martins; Domingos, Gustavo Gontijo; Luciano, Dyego Vilela
Objective: Radiographic assessment of lower limb alignment, in the frontal and sagittal planes, after high tibial osteotomy. To stabilize the osteotomy, a tricortical iliac graft was used, along with a positioning screw. Methods: Prospective study on 46 patients with ages ranging from 17 to 61 years. Among them, 42 patients presented genu varum secondary to knee osteoarthritis and four from other causes. Teleradiography was performed for surgical planning, using the Frank Noyes method, as modified by Fugizawa. A conventional surgical access of 3 cm was made to harvest a tricortical iliac graft. Osteotomy was performed under radioscopic control, by means of an anteromedial incision of 3 cm with release of the superficial portion of the medial collateral ligament. The graft was placed in the posterior portion of the osteotomy, to maintain an unaltered tibial slope. The screw crossed the osteotomy orthogonally to protect the lateral cortex. Pre and postoperative radiographic criteria were established to assess the results. Results: There was consolidation in 100% of the cases and maintenance of the mechanical axis, obtained intraoperatively, in 94% of the cases. The posterior slope of the tibial plateau in the sagittal plane ranged from 7° to 12°. Joint mobility was restored in all the patients. Eleven patients presented temporary pain at the site of graft harvesting, but none had paresthesia. The incidence of complications was 8% (infection, loss of correction and joint fracture). Conclusion: The technique was shown to be reproducible, simple, biological, accurate and low-cost, and it may be an alternative to the existing techniques. PMID:27026961
Lloyd, Selvyn; Rashid, Abdul Halim Abd; Das, Srijit; Ibrahim, Sharaf
Tibial hemimelia is a rare anomaly of unknown etiology. This condition can occur sporadically or may have a familial inheritance. It is characterized by deficiency of the tibia with a relatively intact fibula. The anomaly may be unilateral or bilateral. We report a case of a 2-year-old girl who presented with right lower limb deformity since birth. She was diagnosed with proximal femur focal deficiency with absence of the ipsilateral tibia. She presented with a shorter right lower limb and a deformed foot. She was treated with a through-knee amputation. Anatomical dissection of the amputated limb was carried out to verify the anomalies. The dissection showed that the distal phalanx of the great toe was trifid. The anatomical and clinical significance of this interesting case is discussed.
Cashman, Michael W; Sloan, Steven Brett
The nail is a specialized keratinous skin appendage that grows approximately 2 to 3 mm per month, with complete replacement achieved in 6 to 9 months. Although this structure can be easily overlooked, nail disorders comprise approximately 10% of all dermatologic conditions. This contribution first provides an overview on the basic anatomy of the nail that will delineate between the nail unit (eg, hyponychium, nail bed, proximal nail fold, and matrix) and anatomic components not part of the nail unit (eg, lateral nail folds, nail plate, and eponychium). The function of each nail structure will also be presented. The chemical profile of the normal nail plate is reviewed with a discussion of its keratin content (hair type keratin vs epithelial type keratin), sulfur content, and mineral composition, including magnesium, calcium, iron, zinc, sodium, and copper. The remainder will focus on nail manifestations seen in states of malnutrition. Virtually every nutritional deficiency can affect the growth of the nail in some manner. Finally, the discussion will include anecdotal use of nutritional and dietary supplements in the setting of brittle nail syndrome as well as a brief overview of biotin and its promising utility in the treatment of nail disorders. Copyright 2010 Elsevier Inc. All rights reserved.
Cheema, Gursimrat Singh; Rastogi, Amit; Singh, Vakil; Goel, Satish Chandra; Mishra, Diwakar; Arora, Sumit
Background: Reverse oblique trochanteric fracture of femur is a distinct fracture pattern. 95° Dynamic condylar screw (DCS) and proximal femoral nail (PFN) are currently the most commonly used implants for its fixation. This study aims to biomechanically compare the cutout resistance as well as modes of failure of DCS and PFN in reverse oblique trochanteric fractures. Materials and Methods: Sixteen freshly harvested cadaveric proximal femoral specimens were randomly assigned to three mean bone mineral density matched groups, eight of which were implanted with 95° DCS and the other eight with PFN. The constructs were made unstable to resemble a reverse oblique trochanteric fracture by removing a standard size posteromedial wedge. These constructs were subjected to computer controlled cyclic compressive loading with 200 kg at a frequency of 1 cycle/second (1 Hz) and end points of both the groups were analyzed. Results: The bending moment of the PFN group was approximately 50% less than that of the DCS group (P<0.0001). The PFN group resisted more number of cycles than the DCS group (P=0.03) and showed lesser number of component failures as compared with the DCS group (P=0.003). Conclusions: The PFN is biomechanically superior to DCS for the fixation of reverse oblique trochanteric fractures of femur. PMID:22719110
Acetabular perforation after medial migration of the helical blade through the femoral head after treatment of an unstable trochanteric fracture with proximal femoral nail antirotation (PFNA): a case report.
Takigami, Iori; Ohnishi, Kazuichiro; Ito, Yoshiki; Nagano, Akihito; Sumida, Hisashi; Tanaka, Kaori; Shimizu, Katsuji
The proximal femoral nail antirotation is a new generation of intramedullary device for the treatment of trochanteric femoral fractures, having a helical blade rather than a screw for suggested better purchase in osteoporotic bone. However, it is not free of complications. Few reports are available on postoperative perforation of the helical blade through the femoral head as a unique complication of proximal femoral nail antirotation. We report a 79-year-old woman with acetabular perforation after migration of the helical blade through the femoral head after an unstable trochanteric fracture, which was fixed with a proximal femoral nail antirotation.
Somerson, Jeremy S; Rowley, David; Kennedy, Chad; Buttacavoli, Frank; Agarwal, Animesh
To compare the time required for proximal locking screw placement between a standard freehand technique and the navigated technique, and to quantify the reduction in ionizing radiation exposure. A fresh frozen cadaver model was used for 48 proximal interlocking screw procedures. Each procedure consisted of insertion of 2 anteroposterior locking screws. Standard fluoroscopic technique was used for 24 procedures, and an electromagnetic navigation system was used for the remaining 24 procedures. Procedure duration was recorded using an electronic timer and radiation doses were documented. Mean total insertion time for both proximal interlocking screws was 405 ± 165.7 seconds with the freehand technique and 311 ± 78.3 seconds in the navigation group (P = 0.002). All procedures resulted in successful locking screw placement. Mean ionizing radiation exposure time for proximal locking was 29.5 ± 12.8 seconds. Proximal locking screw insertion using the navigation technique evaluated in this work was significantly faster than the standard fluoroscopic method. The navigated technique is effective and has the potential to prevent ionizing radiation exposure.
González Maza, Carlos; Moscoso López, Luis; Magaña García, Ignacio; Mejía Vargas, Gildardo; López Segundo, José Román
The purpose of the present study is to report sixty six high tibial lateral osteotomies (HTO) make on patients with osteoarthrosis of the medial compartment, using modified semi invasive technique. With this technique the incision is 5-6 mm, fibular head is not resect, biceps femoris tendon is not cut, no internal fixation is place; the median follow-up was 6.4 years. The status of the patient at the final follow-up was analyzed using Knee Society Score (KSS), and Visual Analogue Scale (VAS). An average of 85 points was achieved after HTO compared to 55 points preoperative and 83 points after HTO compared to 51 points preoperative, was obtained at the evaluation with KSS. The only complication was superficial infections (4%). Serious complications did not appear. There was not pseudoarthrosis.
Swami, Vimarsha Gopal; Mabee, Myles; Hui, Catherine; Jaremko, Jacob Lester
To aid in performing anatomic physeal-sparing anterior cruciate ligament (ACL) reconstruction, it is important for surgeons to have reference data for the native ACL attachment positions and epiphyseal anatomy in skeletally immature knees. To characterize anatomic parameters of the ACL tibial insertion and proximal tibial epiphysis at magnetic resonance imaging (MRI) in a large population of skeletally immature knees. Cross-sectional study; Level of evidence, 3. The ACL tibial attachment site and proximal epiphysis were examined in 570 skeletally immature knees with an intact ACL (age, 6-15 years) using 1.5-T proton density-weighted sagittal MRI; also measured were the tibial anteroposterior diameter; anterior, central, and posterior ACL attachment positions; vertical height of the epiphysis; and maximum oblique epiphyseal depth extending from the ACL tibial attachment center to the tibial tuberosity. In adolescents (11-15 years of age), the center of the ACL's tibial attachment was 51.5% ± 5.7% of the anteroposterior diameter of the tibia, with no significant differences between sexes or age groups (P > .05 in all cases). Mean vertical epiphyseal height was 15.9 ± 1.7 mm in the adolescent group, with significant differences between 11-year-olds (15.2 ± 1.5 mm) and 15-year-olds (16.6 ± 1.6 mm), P < .001, and between males (16.6 ± 1.5 mm) and females (14.8 ± 1.4), P < .001. Mean maximum oblique depth was 30.0 ± 5.3 mm, with a significant difference between 11-year-olds (26.7 ± 4.9 mm) and 15-year-olds (32.7 ± 5.1 mm), P < .001, and between males (29.7 ± 6.4 mm) and females (27.8 ± 5.2 mm), P < .001. The maximum oblique depth occurred at a mean angle of ~50°, and this angle did not change with age or sex. There was a significant moderate correlation (r = 0.39, P < .001) between epiphyseal vertical height and maximum oblique depth. The center of the ACL tibial attachment was consistently near 51% of the anteroposterior diameter, regardless of age or sex
Landis, Emily K.; Karnick, Pushpak
This study uses new three-dimensional imaging techniques to compare the articular curvature of the proximal tibial articular surface of hominoids. It has been hypothesized that the curvature of the anteroposterior contour of the lateral condyle in particular can be used to differentiate humans and apes and reflect locomotor function. This study draws from a large comparative sample of extant hominoids to obtain quantitative curvature data. Three-dimensional models of the proximal tibiae of 26 human, 15 chimpanzee, 15 gorilla, 17 orangutan, 16 gibbon and four Australopithecus fossil casts (AL 129-1b, AL 288-1aq, AL 333x-26, KNM-KP 29285A) were acquired with a Cyberware Model 15 laser digitizer. Curvature analysis was accomplished using a software program developed at Arizona State University's Partnership for Research In Stereo Modeling (PRISM) lab, which enables the user to extract curvature profiles and compute the difference between analogous curves from different specimens. Results indicate that the curvature of chimpanzee, gorilla and orangutan tibiae is significantly different from the curvature of human tibiae, thus supporting the hypothesized dichotomy between humans and great apes. The non-significant difference between gibbons and all other taxa indicates that gibbons have an intermediate pattern of articular curvature. All four Australopithecus tibia were aligned with the great apes.
Olerud, C; Danckwardt-Lillieström, G; Olerud, S
Two cases of genu recurvatum deformity and leg length discrepancy after partial growth arrest of the proximal tibial physis are described. The patients are both boys thirteen and fifteen years old respectively. The etiology of the deformity is considered to be local pressure on the tibial tuberosity, in the first case after treatment with plaster cast after correction of an angular deformity in a tibial fracture and in the second case after prolonged treatment with patellar tendon bearing brace. The boys were treated with physeal distraction which corrected both the leg length discrepancy and the angular deformity. The technique is recommended because the correction is done at the site of the deformity and knee motion is possible during the entire treatment period.
Xue, Li; Zha, Li; Chen, Qin; Liang, Yi-jian; Li, Kang-ren; Zhou, Zheng; Guan, Jin-long; Qin, Hui; Li, You-ping
The objective of this study was to compare the clinical results and complications of proximal femoral nail antirotation (PFNA) on treatment of intertrochanteric fractures in 120 elderly Chinese patients using Randomized Controlled Trials (RCTs). Totaly 120 cases enrolled were randomly assigned to a lateral decubitus position group and supine position group. The hospital stay, operating time, intraoperative blood loss, length of incision, X-ray fluoroscopy time, and out-of-bed activity time in the lateral decubitus position group were significantly lower than those in the supine position group. There was not statistical significance on union time and Harris values in the two position groups. Moreover, only complications of superficial wound infection were observed in the lateral decubitus position group, but two complications of deep venous thrombosis and wound deep infection were found in the supine position group. The present findings suggested that PFNA applied in elderly patients with intertrochanteric fracture can get satisfactory effects, and the treatment of intertrochanteric fractures using lateral decubitus position showed a satisfactory clinical outcome and a lower radiological complication rate.
Xue, Li; Zha, Li; Chen, Qin; Liang, Yi-jian; Li, Kang-ren; Zhou, Zheng; Guan, Jin-long; Qin, Hui; Li, You-ping
The objective of this study was to compare the clinical results and complications of proximal femoral nail antirotation (PFNA) on treatment of intertrochanteric fractures in 120 elderly Chinese patients using Randomized Controlled Trials (RCTs). Totaly 120 cases enrolled were randomly assigned to a lateral decubitus position group and supine position group. The hospital stay, operating time, intraoperative blood loss, length of incision, X-ray fluoroscopy time, and out-of-bed activity time in the lateral decubitus position group were significantly lower than those in the supine position group. There was not statistical significance on union time and Harris values in the two position groups. Moreover, only complications of superficial wound infection were observed in the lateral decubitus position group, but two complications of deep venous thrombosis and wound deep infection were found in the supine position group. The present findings suggested that PFNA applied in elderly patients with intertrochanteric fracture can get satisfactory effects, and the treatment of intertrochanteric fractures using lateral decubitus position showed a satisfactory clinical outcome and a lower radiological complication rate. PMID:23606811
Ma, Y. F.; Jee, W. S. S.; Ke, H. Z.; Lin, B. Y.; Liang, X. G.; Li, M.; Yamamoto, N.
The purpose of this study was to determine if human parathyroid hormone-(1-38) (PTH) can restore cancellous bone mass to the established osteopenic, immobilized proximal tibial metaphyses (PTM) of female rats. The right hindlimbs of six-month-old female Sprague-Dawley rats were immobilized by bandaging the right hindlimbs to the abdomen. After 30 days of right hindlimb immobilization (RHLI), the rats were subcutaneously injected with 200 microgram hPTH(1-38)/kg/day for 15 (short-term) or 75 (longer-term) days. Static bone histomorphometry was performed on the primary spongiosa, while both static and dynamic histomorphometry were performed on the secondary spongiosa of the right PTM. Immobilization for 30 days without treatment decreased trabecular bone area, number and thickness in both primary and secondary spongiosa, and induced an increase in eroded perimeter and a decrease in tissue referent-bone formation rate (BFR/TV) in the secondary spongios. These changes reached a new steady state thereafter. Treatment with 200 microgram hPTH(1-38)/kg/day for 15 days, beginning at 30 days post immobilization (IM), significantly increased trabecular bone area, thickness and number in both primary and secondary spongiosa despite continuous IM when compared to the age-related and IM controls. The short-term (15 days) PTH treatment significantly increased labeling perimeter, mineral apposition rate and BFR/TV in the secondary spongiosa and stimulated longitudinal bone growth as compared to the age-related and IM controls. PTH treatment for longer-term (75 days) further increased trabecular bone area, thickness and number as compared to aging and IM controls and short-term (15 days) PTH treated groups. The bone formation indices in the secondary spongiosa of these longer-term treated rats were lower than that of short-term (15 days) PTH treated group, but they were still higher than those of IM and age-related controls. Our findings indicate that PTH treatment stimulates
Tony, G; Charran, A; Tins, B; Lalam, R; Tyrrell, P N M; Singh, J; Cool, P; Kiely, N; Cassar-Pullicino, V N
Stress induced injuries affecting the physeal plate or cortical bone in children and adolescents, especially young athletes, have been well described. However, there are no reports in the current English language literature of stress injury affecting the incompletely ossified epiphyseal cartilage. We present four cases of stress related change to the proximal tibial epiphysis (PTE) along with their respective magnetic resonance imaging (MRI) appearances ranging from subtle oedema signal to a pseudo-tumour like appearance within the epiphyseal cartilage. The site and pattern of intra-epiphyseal injury is determined by the type of tissue that is affected, the maturity of the skeleton and the type of forces that are transmitted through the tissue. We demonstrate how an awareness of the morphological spectrum of MRI appearances in intra-epiphyseal stress injury and the ability to identify concomitant signs of stress in other nearby structures can help reduce misdiagnosis, avoid invasive diagnostic procedures like bone biopsy and reassure patients and their families. Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.
Kaewpornsawan, Kamolporn; Tangsataporn, Suksan; Jatunarapit, Ratiporn
To find the effectiveness of the early surgery (2-3 years of age)as a very important prognostic factor affecting the outcomes in Thai children with infantile tibia vara and all the prognostic factors including the usefulness of arthrographic study in correcting the deformity. From 1994 to 2004, sixteen children aged average 3.61 years old (2.08-7.0) were treated in Siriraj Hospital and diagnosed as infantile tibia vara by Langenskiold radiographic staging were included in the present study and retrospectively reviewed with an average of 6.4 years follow up (range 6 month - 11.1 years). All cases were initially treated by surgery because of low compliance for brace or brace failure. They consisted of 3 boys and 13 girls. There were 24 legs including the bilateral involvement in 8 cases (2 boy and 6 girls). After arihrography, the midshaft fibular osteotomy was performed then the proximal tibial dome-shaped valgus osteotomy was done and fixed with 2 pins. The desired position was 12 degree knee valgus . The patients were divided in two groups, 1)group A,the successful group with the knee becoming normal without any deformity after single osteotomy, 2)group B,the recurrent group with recurrence of the varus deformity required further corrective osteotomies to make normal axis of the knee. All variables were analyzed and compared between group A and group B. The general characteristics and radiographic findings were recorded in 1)age, 2)sex, 3)side, 4)weight in kilogram and in percentage of normal or overweight(obesity) compared with the standard Thai weight chart, 5)tibiofemoral angle (TFA) pre and postoperative treatment, 6) metaphyseal diaphyseal angle (MDA), 7)the medial physeal slope angle (MPS, 8)The preoperative arthrographic articulo-diaphyseal angle (ADA), 9.arthrographic articulo-medial physeal angle (AMPA). There were 14 legs in group A and the remaining 10 legs were in group B (average 2.4 operations). All cases healed in good alignment of the legs without
Linhart, W; Briem, D; Amling, M; Rueger, J M; Windolf, J
The treatment of osseous defects is widely established in the elderly. The number of positive reports on the successful application of bovine as well as coralline hydroxyapatite ceramics has continuously increased during the last few years. In trauma surgery hydroxyapatite ceramics are most commonly applied in metaphyseal defects evoked by traumatic fractures of the long bones. The bovine and coralline materials applied are biocompatible and exhibit an interconnecting porous system. Good osteoconductive properties of such materials have repeatedly been demonstrated. Due to possible harmful effects caused by abrasion of the material, intra-articular application should be strictly avoided. Biological degradation of the materials does not occur even during long-term follow-up. The application of hydroxyapatite ceramics was introduced at our institution in 1992. Since then, no adverse events have been observed and only a few relevant complications were described in the literature. We report on a patient revealing a mechanical failure of a bovine hydroxyapatite (Endobon) 7.5 years after implantation into a metaphyseal defect of the proximal tibia caused by a traumatic fracture.
Leary, Jeffrey; Werger, Matthew; Sagebien, Carlos
Intramedullary nailing (IMN) of tibial shaft fractures is an excellent treatment option associated with low complication rates. Suprapatellar intramedullary nailing (SIMN) is a viable alternative treatment to traditional IMN, especially for proximal fractures of the tibia. There are, however, clinical concerns regarding SIMN removal that pose a challenge to a successful outcome. This article describes a novel percutaneous technique for the removal of a SIMN using the same instruments and incision used for nail insertion. This technical innovation offers a simple, reliable, and minimally invasive approach for the removal of any IMN, including nails inserted via a suprapatellar approach. The technique is demonstrated here on a cadaveric specimen as well as with a sawbones model.
Ushio, Tetsuro; Mizu-Uchi, Hideki; Okazaki, Ken; Ma, Yuan; Kuwashima, Umito; Iwamoto, Yukihide
We evaluated the effect of cutting surface on the anteroposterior (AP) axis of the proximal tibia using a 3-dimensional (3D) bone model to ensure proper tibial rotational alignment in total knee arthroplasty. 3D bone models were reconstructed from the preoperative computed tomography data of 93 Japanese osteoarthritis knees with varus deformity. The AP axis was defined as the perpendicular bisector of the medial and lateral condylar centers in a 3D coordinate system. Bone cutting of the proximal tibia was performed with various tibial posterior slopes (0°, 3°, 7°) to the mechanical axis, and we compared the AP axes before and after bone cutting. The AP axis before bone cutting crossed a point at about 16% (one-sixth) of the distance from the medial edge of the patellar tendon at its tibial attachment. The AP axis after bone cutting was significantly internally rotated at all posterior slopes: 4.1° at slope 0°, 3.0° at slope 3°, and 2.1° at slope 7°. The percentages of cases with differences of more than 3° or 5° were 66.7% and 34.4% at slope 0°, 53.8% and 24.7% at slope 3°, and 38.3% and 11.8% at slope 7°, respectively. The AP axis of the proximal tibia may be rotated internally after resection of the proximal tibia in total knee arthroplasty. Hence, surgeons should recognize the effect of changes in the cutting surface on rotational alignment of the proximal tibia. Copyright © 2016 Elsevier Inc. All rights reserved.
Aguado-Maestro, I; Escudero-Marcos, R; García-García, J M; Alonso-García, N; Pérez-Bermejo D, D; Aguado-Hernández, H J; Nistal-Rodríguez, J; García-Alonso, M
Evaluation of the surgical management, outcome and complications in patients with pertrochanteric fractures treated with PFNA nail. A retrospective study was conducted on 200 patients treated consecutively between April 2010 and February 2012. Radiological assessments were performed before and after the surgery, and during the follow-up (fracture reduction, blade position, consolidation or collapse signs). A clinical evaluation was performed as regards walking capabilities. The results were compared with those of a previous study on 700 patients treated with gamma 3 and TFN nails. The blade position was centre-centre in 64% of patients, and decreased to 53% in the mechanical complications group. Tip-apex distance was less than 25mm in 91.5%. The average hospital stay was 9.17 days, with a mean post-surgery stay of 5.95 days. Complications (7.5%): 2 cut out (1%), one cut through (0.5%), 4 cases of helical blade sliding (2%), one failure in distal locking procedure (0.5%), 2 cases with painful fasciae latae (1%), one union delay (0.5%), 2 cases of non-union with hardware failure (1%), one case of intense bleeding related to distal locking of the nail (0.5%), and one case of avascular necrosis (0.5%). The PFNA helical blade system seems to reduce the incidence of cut out and cut through in osteoporotic bone. Blade position was one of the main parameters associated with mechanical complications. Copyright © 2013 SECOT. Published by Elsevier Espana. All rights reserved.
Hennig, Alex C; Incavo, Stephen J; Beynnon, Bruce D; Abate, Joseph A; Urse, John S; Kelly, Stephen
Twenty opening wedge tibial osteotomies were performed using the Osteotrac plate, which consists of a two-piece plate with a one-way ratcheting mechanism with two degrees of freedom. A variety of concomitant procedures were performed including osteochondral transfer, tibial tubercle medialization, and anterior cruciate ligament reconstruction. The change in tibiofemoral alignment in the coronal plane and the shift in lower extremity mechanical axis were determined. The average lateral shift in the lower extremity mechanical axis was 24% of the tibial plateau width. The average change in the mechanical tibiofemoral angle was 7 degrees of valgus. Union rate at the osteotomy site was 95%. No deep infections, clinical deep venous thrombosis, or device failures occurred. The Osteotrac plate provides safe and effective fixation and intraoperative adjustability to achieve and maintain a lateral shift of the lower extremity mechanical axis and valgus correction of the tibiofemoral alignment in patients with varus knees undergoing proximal tibial opening wedge osteotomy and associated meniscal and chondral procedures.
Bries, Andrew D; Weiner, Dennis S; Jacquet, Robin; Adamczyk, Mark J; Morscher, Melanie A; Lowder, Elizabeth; Askew, Michael J; Steiner, Richard P; Horne, Walter I; Landis, William J
The effect of compression on the physis is generally defined by the Hueter-Volkmann principle, in which decreased linear growth of the physis results from increased compression. This investigation examined whether mechanically induced compression of rabbit physes causes changes in gene expression, cells, and extracellular components that promote physeal resilience and strength (type-II collagen and aggrecan) and cartilage hypertrophy (type-X collagen and matrix metalloprotease-13). Static compressive loads (10 N or 30 N) were applied for two or six weeks across one hind limb proximal tibial physis of thirteen-week-old female New Zealand White rabbits (n = 18). The contralateral hind limb in all rabbits underwent sham surgery with no load to serve as an internal control. Harvested physes were divided into portions for histological, immunohistochemical, and quantitative reverse transcription-polymerase chain reaction analysis. Gene expression was statistically analyzed by means of comparisons between loaded samples and unloaded shams with use of analysis of variance and a Tukey post hoc test. Compared with unloaded shams, physes loaded at 10 N or 30 N for two weeks and at 10 N for six weeks showed histological changes in cells and matrices. Physes loaded at 30 N for six weeks were decreased in thickness and had structurally disorganized chondrocyte columns, a decreased extracellular matrix, and less intense type-II and X collagen immunohistochemical staining. Quantitative reverse transcription-polymerase chain reaction analysis of loaded samples compared with unloaded shams yielded a significantly (p ≤ 0.05) decreased gene expression of aggrecan and type-II and X collagen and no significant (p > 0.05) changes in the matrix metalloprotease-13 gene expression with increasing load. Compressed rabbit physes generate biochemical changes in collagens, proteoglycan, and cellular and tissue matrix architecture. Changes potentially weaken overall physeal strength
Ekizoglu, Oguzhan; Hocaoglu, Elif; Inci, Ercan; Can, Ismail Ozgur; Aksoy, Sema; Kazimoglu, Cemal
Radiation exposure during forensic age estimation is associated with ethical implications. It is important to prevent repetitive radiation exposure when conducting advanced ultrasonography (USG) and magnetic resonance imaging (MRI). The purpose of this study was to investigate the utility of 3.0-T MRI in determining the degree of ossification of the distal femoral and proximal tibial epiphyses in a group of Turkish population. We retrospectively evaluated coronal T2-weighted and turbo spin-echo sequences taken upon MRI of 503 patients (305 males, 198 females; age 10-30 years) using a five-stage method. Intra- and interobserver variations were very low. (Intraobserver reliability was κ=0.919 for the distal femoral epiphysis and κ=0.961 for the proximal tibial epiphysis, and interobserver reliability was κ=0.836 for the distal femoral epiphysis and κ=0.885 for the proximal tibial epiphysis.) Spearman's rank correlation analysis indicated a significant positive relationship between age and the extent of ossification of the distal femoral and proximal tibial epiphyses (p<0.001). Comparison of male and female data revealed significant between-gender differences in the ages at first attainment of stages 2, 3, and 4 ossifications of the distal femoral epiphysis and stage 1 and 4 ossifications of the proximal tibial epiphysis (p<0.05). The earliest ages at which ossification of stages 3, 4, and 5 was evident in the distal femoral epiphysis were 14, 17, and 22 years in males and 13, 16, and 21 years in females, respectively. Proximal tibial epiphysis of stages 3, 4, and 5 ossification was first noted at ages 14, 17, and 18 years in males and 13, 15, and 16 years in females, respectively. MRI of the distal femoral and proximal tibial epiphyses is an alternative, noninvasive, and reliable technique to estimate age.
... under the surface. Nails start in the nail root , hidden under the cuticle. When cells at the root of the nail grow, the new nail cells ... nail as it grows out from the nail root. The lunula (say: LOON-yuh-luh) — which comes ...
Johnson, M D; Lewis, D D; Winter, M D
A 4-month-old female intact American Pit Bull Terrier was presented for right pelvic limb lameness 1 day after the dog had been hit by an all-terrain vehicle. Orthogonal radiographs of the right stifle revealed a Salter-Harris type IV fracture through the proximal tibial physis extending caudodistally through the proximal tibial metaphysis. The distal tibia was markedly displaced cranially, laterally and proximally, resulting in complete overriding of the fracture segments. An open approach was made in order to facilitate direct reduction, but the fracture could not be sufficiently distracted and the epiphyseal segment remained fixed caudal to the remainder of the tibia. Concerns regarding possible iatrogenic trauma to the epiphysis prompted the use of a transarticular circular fixator construct to distract the fracture segments to facilitate reduction. Distraction that facilitated reduction was performed using three TrueLok Rapid Quick Adjust Struts that were positioned between the two ring components. The struts also allowed for multiplanar adjustment of alignment, which allowed the fracture to be maintained in anatomic reduction as divergent interfragmentary Kirschner wires were placed. Radiographic union was confirmed 19 days after surgery. Transient intraoperative application of a circular construct incorporating the TrueLok components facilitated accurate fracture reduction without inflicting further iatrogenic trauma to the epiphysis, after traditional direct reduction techniques proved ineffective, and afforded a successful clinical outcome in the dog reported here. © 2017 Australian Veterinary Association.
Kim, Gyeong Min; Nam, Kwang Woo; Seo, Kyu-Bum; Lim, Chaemoon; Kim, Jiyun; Park, Yong-Geun
The purpose of this study was to introduce a new surgical technique, that involves modified Candy-package wiring followed by IM nailing fixation and to determine the clinical and radiological results obtained in patients with unstable intertrochanteric fractures with a lesser trochanter fragment. This study included 22 patients who were undergone proximal IM nailing with lesser trochanter wiring between January 2014 to June 2015. All patients were treated with minimally invasive technique of candy-package wiring for lesser trochanter fragments. The mean age was 75.8 years (range, 53-88) and average follow-up period was 15.1 months (range, 12-24). Each patient was followed up for a minimum of 12 months and their clinical and radiological results were analyzed. The mean period required for fracture union was 16.6 weeks. (range, 8-25) and union was successfully completed in all cases. The WOMAC scores at the last F/U visit (average; 45.4, range; 21-75) were not significantly different to pre-trauma status (average; 36.5, range; 19-59) (p=0.087). In comparison of ambulatory capacity prior to trauma, ambulatory aggravation was noted in four cases (18.2%), and eighteen cases (81.8%) was sustained walking ability of prior of trauma. Wiring breakage was found in two cases and heterotrophic ossification in one case. There were no functional deficeit related to the radiologic finding in these patients. With regard to postoperative complications, were no cut-outs, breakage, or pullout of screws. When surgically repairing unstable intertrochanteric fractures with lesser trochanter comminution using proximal IM nailing method, the modified Candy-packaging wiring technique increases the fixation force at the fracture site. Thus, through this technique, both firm fixation of the lesser trochanter and more stable bony union were obtained. Copyright © 2016 Elsevier Ltd. All rights reserved.
Purpose We aimed to evaluate and compare the clinical and functional outcomes of dynamic hip screw (DHS) and proximal femoral nail antirotation (PFNA) treatment of AO type 1 intertrochanteric fractures in elderly patients. Materials and Methods We retrospectively reviewed 194 consecutive patients with type A1 intertrochanteric femoral fractures who were treated with DHS (n=113) or PFNA (n=81). We evaluated operation time, intraoperative blood loss, and functional outcomes, walking ability, and the Barthel activities index. Fracture union, sliding of hip screw, proximal femur shortening, and presence of complications were assessed radiologically at relevant follow-up intervals. Results The mean operation time and blood loss were significantly lower for the PFNA group, but walking ability and Barthel index decreased to a similar extent for both groups. However, patients in the DHS group complained of significantly more pain (P=0.049). Although there were no significant differences between the two groups with respect to the time until fracture union was achieved, patients in the DHS group exhibited a higher extent of proximal femoral shortening and sliding of the hip screw. Differences about hip screw sliding and proximal femur shortening within each subgroup were not significant. Conclusion Compared to DHS treatment, PFNA treatment of type A1 intertrochanteric fractures is associated with reduced blood loss, shorter operation time, and less severe pain after surgery. Additionally, sliding of the hip screw and proximal femur shortening are expected to occur more frequently after DHS. PMID:28097113
Bungaro, P; Ruggieri, P; Pavone, S; Vendemia, V
The authors reviewed 73 patients treated by delayed osteosynthesis with a "Tour Eiffel" double Rush nail. The cases involved fracture of the lower third of the femur in 20 patients, fracture of the proximal third of the tibia in 24 cases, and fracture of the distal third of the tibia in 29. The results indicate the effectiveness of the method, despite the fact that its use was reduced as a result of the introduction of the Grosse-Kempf nail. This is however the method of choice for tibial meta-diaphyseal fractures associated with fracture of the tibial plateaux and complex and comminuted fractures of the distal fourth of the tibia. Moreover, this method must be used three-six weeks after the fracture, when the callus formation is in progress.
Madnani, Nina A; Khan, Kaleem J
The nail as an anatomic structure protects the terminal phalanx of the digit from injury. Historically, it has served as a tool for protection and for survival. As civilizations developed, it attained the additional function of adornment. Nail beautification is a big industry today, with various nail cosmetics available, ranging from nail hardeners, polishes, extensions, artificial/sculpted nails, and nail decorations. Adverse events may occur either during the nail-grooming procedure or as a reaction to the individual components of the nail cosmetics. This holds true for both the client and the nail technician. Typically, any of the procedures involves several steps and a series of products. Separate "nail-bars" have been set up dedicated to serve women and men interested in nail beautification. This article attempts to comprehensively inform and educate the dermatologist on the services offered, the products used, and the possible/potential adverse effects related to nail-grooming and nail cosmetics.
Starr, Adam J; Hay, Michael T; Reinert, Charles M; Borer, Drake S; Christensen, Kevin C
The purpose of this study is to compare a cephalomedullary nail that uses a piriformis fossa starting point to one that uses a trochanteric starting point, in the treatment of high-energy proximal femur fractures in young patients. Our hypothesis was that a nail that uses a trochanteric starting point would result in less blood loss than a nail that uses a piriformis fossa starting point. Prospective, randomized. Level 1 trauma center. Thirty-four consecutive patients aged between 18 and 50 years who sustained a subtrochanteric, intertrochanteric, or ipsilateral femoral neck/shaft fracture due to a high-energy injury were enrolled. Patients were randomized to have their fractures repaired with a Russell-Taylor Recon Nail or Howmedica Long Gamma Nail. Surgery was performed on a fracture table, in supine or lateral position according to the surgeon's preference. Direct fracture exposure was avoided. Reduction was obtained through traction, patient positioning, and manual pressure. If necessary, stab-wound incisions were made to introduce instruments to improve reduction. Intramedullary reamers were used, and all nails were statically locked. Bone grafting was not used. Blood loss, incision length, duration of surgery, and body mass index were recorded for each patient. Surgeon's assessment of ease of use of the device and quality of reduction were noted. Patients were to be followed up to assess fracture union. Hip and knee ranges of motion at latest follow-up were measured. Radiographs obtained at the time of union were assessed for varus malalignment. Return to work status was recorded, and the Harris Hip Score was used to assess hip function. There were 17 patients in each group. The 2 groups did not differ with regard to blood loss, incision length, and duration of surgery or intraoperative complications. Body mass index was significantly linked to duration of surgery (P<0.001) and incision length (P<0.001). Surgeon's assessment of ease of use and reduction
Iorizzo, Matilde; Piraccini, Bianca Maria; Tosti, Antonella
The clinical features of nail dystrophies depend on the part of the nail that has been damaged. Due to the important functions of fingernails and toenails, any abnormality of the nail causes impaired function of the hand or foot. Moreover, the aesthetic aspect of the nail may affect employability, self-esteem, and interaction with other people. Because the nails are often difficult to treat, cosmetology may be an effective support to medical treatment. Nail cosmetics may help the patient to cope with his or her nail dystrophy while waiting for treatment to show its efficacy. It may also be the only choice to hide nail dystrophy where the nail is irreversibly damaged. Nail cosmetics may also function at treatment for onychtillomania, nail biting, and nail ingrowing.
Six techniques not yet widely known or used in the dermatologic surgery of the nails are briefly described. Small-to-medium-sized tumours of the proximal nail fold (PNF) can be excised and the defect repaired with advancement or rotation flaps. A superficial biopsy technique of the matrix for the diagnosis of longitudinal brown streaks in the nail, which allows rapid histological diagnosis of the melanocyte focus to be performed, is described here. Because the excision is very shallow and leaves the morphogenetic connective tissue of the matrix intact, the defect heals without scarring. Laterally positioned nail tumours can be excised in the manner of a wide lateral longitudinal nail biopsy. The defect repair is performed with a bipedicled flap from the lateral aspect of the distal phalanx. Malignant tumours of the nail organ often require its complete ablation. These defects can be covered by a full-thickness skin graft, reversed dermal graft, or cross-finger flap. The surgical correction of a split nail is often difficult. The cicatricial tissue of the matrix and PNF have to be excised and the re-attachment of these wounds prevented. The matrix defect has to be excised and sutured or covered with a free matrix graft taken either from the neighbouring area or from the big toe nail. PMID:22279381
The nail unit is the largest and a rather complex skin appendage. It is located on the dorsal aspect of the tips of fingers and toes and has important protective and sensory functions. Development begins in utero between weeks 7 and 8 and is fully formed at birth. For its correct development, a great number of signals are necessary. Anatomically, it consists of 4 epithelial components: the matrix that forms the nail plate; the nail bed that firmly attaches the plate to the distal phalanx; the hyponychium that forms a natural barrier at the physiological point of separation of the nail from the bed; and the eponychium that represents the undersurface of the proximal nail fold which is responsible for the formation of the cuticle. The connective tissue components of the matrix and nail bed dermis are located between the corresponding epithelia and the bone of the distal phalanx. Characteristics of the connective tissue include: a morphogenetic potency for the regeneration of their epithelia; the lateral and proximal nail folds form a distally open frame for the growing nail; and the tip of the digit has rich sensible and sensory innervation. The blood supply is provided by the paired volar and dorsal digital arteries. Veins and lymphatic vessels are less well defined. The microscopic anatomy varies from nail subregion to subregion. Several different biopsy techniques are available for the histopathological evaluation of nail alterations.
Optimizing finite element predictions of local subchondral bone structural stiffness using neural network-derived density-modulus relationships for proximal tibial subchondral cortical and trabecular bone.
Nazemi, S Majid; Amini, Morteza; Kontulainen, Saija A; Milner, Jaques S; Holdsworth, David W; Masri, Bassam A; Wilson, David R; Johnston, James D
Quantitative computed tomography based subject-specific finite element modeling has potential to clarify the role of subchondral bone alterations in knee osteoarthritis initiation, progression, and pain. However, it is unclear what density-modulus equation(s) should be applied with subchondral cortical and subchondral trabecular bone when constructing finite element models of the tibia. Using a novel approach applying neural networks, optimization, and back-calculation against in situ experimental testing results, the objective of this study was to identify subchondral-specific equations that optimized finite element predictions of local structural stiffness at the proximal tibial subchondral surface. Thirteen proximal tibial compartments were imaged via quantitative computed tomography. Imaged bone mineral density was converted to elastic moduli using multiple density-modulus equations (93 total variations) then mapped to corresponding finite element models. For each variation, root mean squared error was calculated between finite element prediction and in situ measured stiffness at 47 indentation sites. Resulting errors were used to train an artificial neural network, which provided an unlimited number of model variations, with corresponding error, for predicting stiffness at the subchondral bone surface. Nelder-Mead optimization was used to identify optimum density-modulus equations for predicting stiffness. Finite element modeling predicted 81% of experimental stiffness variance (with 10.5% error) using optimized equations for subchondral cortical and trabecular bone differentiated with a 0.5g/cm(3) density. In comparison with published density-modulus relationships, optimized equations offered improved predictions of local subchondral structural stiffness. Further research is needed with anisotropy inclusion, a smaller voxel size and de-blurring algorithms to improve predictions. Copyright © 2016 Elsevier Ltd. All rights reserved.
Fleckman, Philip; Jaeger, Karin; Silva, Kathleen A; Sundberg, John P
Recent studies of mice with hair defects have resulted in major contributions to the understanding of hair disorders. To use mouse models as a tool to study nail diseases, a basic understanding of the similarities and differences between the human and mouse nail unit is required. In this study we compare the human and mouse nail unit at the macroscopic and microscopic level and use immunohistochemistry to determine the keratin expression patterns in the mouse nail unit. Both species have a proximal nail fold, cuticle, nail matrix, nail bed, nail plate, and hyponychium. Distinguishing features are the shape of the nail and the presence of an extended hyponychium in the mouse. Expression patterns of most keratins are similar. These findings indicate that the mouse nail unit shares major characteristics with the human nail unit and overall represents a very similar structure, useful for the investigation of nail diseases and nail biology.
Aldahan, Adam S.; Chen, Lucy L.; Fertig, Raymond M.; Holmes, Jon; Shah, Vidhi V.; Mlacker, Stephanie; Hsu, Vincent M.; Nouri, Keyvan; Tosti, Antonella
Background Nail psoriasis is a painful and disfiguring nail disease that often leads to invasive biopsies. Dermoscopy of the hyponychium can be useful in the diagnosis showing twisted coiled vessels. Structural features of nail psoriasis have been described with optical coherence tomography (OCT). Objectives To investigate vascular features of nail psoriasis using dynamic OCT. Methods This was an observational, prospective, controlled study in which psoriasis patients with psoriatic nail changes and healthy control patients underwent OCT imaging of the distal nail plate and proximal nail fold. Vertical and horizontal OCT images were analyzed to describe structural and vascular features and to quantify blood flow at depth. Results Sixteen psoriatic nails and 16 control nails were included. Psoriatic nails had significantly increased blood flow in the proximal nail fold at depths of 0.72 mm (p = 0.035) and 0.76 mm (p = 0.027). Nail thickness was significantly greater in psoriatic nails compared to control nails (p = 0.0016). Compared to control nails, psoriatic nails had dilated, disorganized blood vessels superficially in the proximal nail fold. Limitations The main limitation of our study is the relatively small sample size. Conclusions OCT can identify structural and vascular features specific to nail psoriasis. PMID:28232916
Double-level osteotomy and one-stage reconstruction with long intramedullary femoral nail to correct a severe proximal and diaphyseal femur deformity in a patient with polyostotic fibrous dysplasia: case report and literatures review
Chen, Feiyan; Wei, Yibing; Xia, Jun; Wu, Jianguo; Wang, Siqun; Huang, Gangyong; Chen, Jie; Shi, Jingsheng
Proximal femur is often involved with varus and retroversion deformity in polyostotic fibrous dysplasia (PFD). Multiple corrective osteotomies with intramedullary nails in two stages is recommended procedure as some authors described. We report a case using double-level osteotomy and one-stage reconstruction with intramedullary nail in a patient with painful proximal femur and diaphysis varus deformity, the neck-shaft angle was corrected from 95° pre-operatively to 125° post-operatively, the patient was free of pain and no evidence of recurrence at the 24-month follow up. The operative design and method were described, and a review of related literatures about the treatment alteration for PFD and relevant operative selection were also performed. PMID:26550394
Clement, Nicholas D; Goswami, Anukul
We present a case of a Salter-Harris II injury to the proximal tibia associated with both vascular compromise and compartment syndrome. The potential complications of this injury are limb threatening and the neurovasular status of the limb should be continually monitored. Maintaining anatomic reduction is difficult and fixation may be needed to achieve optimal results. PMID:19563664
Clement, Nicholas D; Goswami, Anukul
We present a case of a Salter-Harris II injury to the proximal tibia associated with both vascular compromise and compartment syndrome. The potential complications of this injury are limb threatening and the neurovasular status of the limb should be continually monitored. Maintaining anatomic reduction is difficult and fixation may be needed to achieve optimal results.
... and sometimes falls off. Pitting is associated with psoriasis and alopecia areata. Ridges are tiny, raised lines ... cause horizontal depressions in the nails (Beau's lines). Psoriasis may cause pitting, splitting of the nail plate ...
... your nails, he or she is checking your blood circulation. By looking at your nails, a doctor may find changes that may be associated with skin problems, lung disease, anemia, and other medical conditions. Your ...
... de los dientes Video: Getting an X-ray Quiz: Nails KidsHealth > For Kids > Quiz: Nails Print A A A How much do ... about your nails? Find out by taking this quiz! About KidsHealth Nemours.org Reading BrightStart! Contact Us ...
Alli, Nuran; Dogan, Sibel
Elkonyxis and median nail distrophy are very rare nail fold disorders due to the damage in nail matrix and proximal nail fold. Herein, we report a patient with both elkonyxis and median nail distrophy occured two months into a treatment course of isotretinoin that is to our knowledge for the first time.
Sharma, Naveen; Singh, Varun; Agrawal, Ashish; Bhargava, Rakesh
Background: Proximal tibia fractures with compartment syndrome present a challenge for orthopedic surgeons. More often than not these patients are subjected to multiple surgeries and are complicated by infection osteomyelitis and poor rehabilitation. There is no consensus in the management of these fractures. Most common mode is to do early fasciotomy with external fixation, followed by second stage definitive fixation. We performed a retrospective study of proximal tibia fractures with impending compartment syndrome treated by single stage fasciotomy and internal fixation. Results in terms of early fracture union, minimum complications and early patient mobilization were very good. Materials and Methods: Fifteen patients who were operated between July 2011 and June 2012 were selected for the study. All documents from their admission until the last followup in December 2013 were reviewed, data regarding complications collected and results were evaluated using Oxford Knee scoring system. Results: At the final outcome, there was anatomical or near anatomical alignment with no postoperative problems with range of motion of near complete flexion (>120) in all patients within 3 months. 13 patients started full weight bearing walking at 3 months. Delayed union in two patients and skin necrosis in one patient was observed. Conclusions: Since the results are encouraging and the rehabilitation time is much less when compared to conventional approaches, it is recommended using this protocol to perform early fasciotomy with the definitive internal fixation as single stage surgery to obtain excellent followup results and to reduce rehabilitation time, secondary trauma, expense of treatment and infection rate. PMID:26538755
Atmaca, Halil; Özkan, Arif; Mutlu, Ibrahim; Celik, Talip; Ugur, Levent; Kisioglu, Yasin
Proximal tibial open wedge osteotomy (PTO) is a corrective operation used in the surgery of lower extremities and is applied to patients with varus deformities for sufficient correction. The aim of the study was to evaluate whether the PTO can achieve decreased stress-bearing on the tibia and tarsal bones in addition to correcting the mechanical axis of the lower limb in patients with tibia vara. Three-dimensional (3D) solid modelling of the lower extremity was carried out using computed tomography (CT) and magnetic resonance (MR)-containing images of all of the bony elements and non-bony structures. PTO was applied to the obtained deformed model in the computer environment and the correction was carried out. Stress distributions in menisci, tibia and tarsal bones were calculated. With respect to loading on the tarsal bones, the maximum equivalent stresses on all bones decreased except for the navicula in the PTO-simulated model in the current study. These results clearly indicate that PTO can achieve decreased stresses on the tarsal bones in patients with tibia vara. Copyright © 2013 John Wiley & Sons, Ltd.
Ke, Hua Zhu; Jee, Webster S. S.; Mori, Satoshi; Li, Xiao Jian; Kimmel, Donald B.
The effects of long-term prostaglandin E(sub 2) (PGE(sub 2)) on cancellous bone in proximal tibial metaphysis were studied in 7 month old male Sprague-Dawley rats given daily subcutaneous injections of 0, 1, 3, and 6 mg PGE(sub 2)/kg/day and sacrificed after 60, 120, and 180 days. Histomorphometric analyses were performed on double fluorescent-labeled undecalcified bone specimens. After 60 days of treatment, PGE(sub 2) produced diffusely labeled trabecular bone area, increased trabecular bone area, eroded and labeled trabecular perimeter, mineral apposition rate, and bone formation rate at all dose levels when compared with age-matched controls. In rats given PGE(sub 2) for longer time periods (120 and 180 days), trabecular bone area, diffusely labeled trabecular bone area, labeled perimeter, mineral apposition, and bone formation rates were sustained at the elevated levels achieved earlier at 60-day treatment. The eroded perimeter continued to increase until 120 days, then plateau. The observation that continuous systemic PGE(sub 2) administration to adult male rats elevated metaphyseal cancellous bone mass to 3.5-fold of the control level within 60 days and maintained it for another 120 days indicates that the powerful skeletal anabolic effects of PGE2 can be sustained with continuous administration .
Levin, P.E.; Schoen, R.W. Jr.; Browner, B.D.
During interlocking intramedullary nailing of twenty-five femoral and five tibial fractures, the primary surgeon wore both a universal film badge on the collar of the lead apron and a thermoluminescent dosimeter ring on the dominant hand to quantify the radiation that he or she received. When distal interlocking was performed, the first ring was removed and a second ring was used so that a separate recording could be made for this portion of the procedure. At the conclusion of the study, all of the recorded doses of radiation were averaged. The average amount of radiation to the head and neck during the entire procedure was 7.0 millirems of deep exposure and 8.0 millirems of shallow exposure. The average dose of radiation to the dominant hand during insertion of the intramedullary nail and the proximal interlocking screw was 13.0 millirems, while the average amount during insertion of the distal interlocking nail was 12.0 millirems. Both of these averages are well within the government guidelines for allowable exposure to radiation during one-quarter (three months) of a year. Precautions that are to be observed during this procedure are recommended.
Introduction We report a case of proximal tibiofibular dislocation associated with an ipsilateral tibial fracture, a rare association of injuries that can remain undiagnosed. Case presentation A white 23-year-old man experienced a road accident and was diagnosed with proximal tibiofibular dislocation associated with an open fracture of the tibia and injury to the external popliteus sciatic nerve. He was treated immediately with an intramedullary tibial nail and a cancellous screw at the level of the proximal tibiofibular articulation. Conclusion In addition to this case and the surgical treatment, a review of the clinical cases described in the literature is provided, assessing the type of injury and the therapeutic options used, which depend mainly on the stage in which the condition is diagnosed. PMID:20062704
Beltran, Michael J; Collinge, Cory A; Patzkowski, Jeanne C; Masini, Brendan D; Blease, Robert E; Hsu, Joseph R
To determine the risks to local anatomy near the starting point for tibial nailing during suprapatellar nailing, 15 fresh-frozen hemipelvis specimens were nailed using a suprapatellar technique. After nail passage, the menisci and articular surfaces, anterior cruciate ligament (ACL) insertion, intermeniscal ligament, and fat pad were assessed for injury. The distance from the entry portal to the menisci, articular surfaces, and ACL insertion was determined. Medial meniscus injury occurred in 1 (6.7%) specimen and medial articular injury in 2 (13%). Nails passed through the fat pad in all specimens; intermeniscal ligament injury occurred in 3 (20%) specimens. The ACL insertion and lateral structures were not injured in any specimen. The distance from the entry portal margin to the lateral and medial menisci was 6.46±2.47 mm and 4.74±3.17 mm, respectively. The distances to the lateral and medial articular margins measured 10.33±3.62 mm and 6.54±3.57 mm, respectively. The distance to the ACL insertion averaged 5.80±3.94 mm. Suprapatellar nailing is associated with a risk of injury to anterior knee structures comparable to other nailing techniques. Additional clinical studies are warranted to further define the role of this technique in the management of tibial fractures.
The structure of the nail unit is complex and many dermatologists and dermatopathologists have an incomplete understanding of it. Familiarity with the anatomy and histology of this unit, however, is a key factor in improving the diagnostic yield of nail biopsy. Inflammatory or infectious conditions that affect the nail can have a marked impact on a patient's quality of life. A wide-ranging variety of tumors can also develop in this region and they may be life-threatening or require surgery that will result in functional defects. The author reviews the anatomy and histology of the nail unit as well as the basic histopathologic findings in the most common conditions affecting the nails.
Wehner, Tim; Claes, Lutz; Ignatius, Anita; Simon, Ulrich
Due to the annular gap between intramedullary (IM) nails and the endosteal surface, high interfragmentary movement can occur under loading. This could prolong the healing time, particularly for thin IM nails that are often used for unreamed IM nailing. The aims of our study were to determine the influence of the nail diameter on the healing time of human tibial shaft fractures and to investigate whether the healing time could be shortened by increasing the stiffness of the implant material. Therefore, a corroborated numerical model for simulating the fracture healing process in humans was used to simulate the healing process of human tibial fractures treated with IM nails. The calculated healing time (up to 71 weeks) was longest for transverse fractures treated with thin IM nails made of titanium. That the healing time was disproportionately long depended on the nail diameter, and could be greatly reduced by using a thicker nail or using steel instead of titanium. To avoid a prolonged healing time, the nail should be thick, and the annular gap should be as narrow as possible. Alternatively, using steel instead of titanium may also help to avoid a prolonged healing time.
Wang, Bin; Wang, Pengfei; Wang, Yupeng; Jia, Song; Yang, Huanyou; Yin, Jiali; Jiang, Wenping; Zhao, Gang
To provide the anatomical basis for the selection of osteotomy site in leg lengthening or tibial slip. Between August 2010 and July 2014, 10 adult fresh amputated leg specimens were collected. The pressure perfusion of red latex was performed by the popliteal artery. The anterior tibial artery and its main branches were separated and exposed, and the periosteal branch of anterior tibial artery was adequately exposed; the posterior tibial artery and its main branches were exposed; the peroneal artery was separated and exposed. The tibial and peroneal artery and its branches were observed and measured. When measuring the proximal end, the medial tibial plateau bone margin, the most prominent part of the tibial tuberosity, and the fibular head edge were used as a reference; when measuring the distal end, distal medial condyle of tibia malleolus tip, tibial lateral malleolus lateral tip, and distal tibial articular surface were used as a reference; the vertical distance between tibia proximal and distal main arteries and bone end reference was measured to determine the optimal osteotomy position of upper and lower tibia. The osteotomy index was calculated which was used to represent the relative position of osteotomy site in the whole tibia. The proximal tibial osteotomy site located at (78.2 ± 19.5) mm from medial tibial plateau margin, (41.8 ± 16.0) mm from the tibial tuberosity pole, and (66.7 ± 16.4) mm from the fibular head edge. The distal tibial osteotomy site located at (70.8 ± 12.1) mm above the inferior margin of tibial medial malleolus, (83.3 ± 13.0) mm above the inferior margin of lateral malleolus tip, and (59.1 ± 11.7) mm from distal tibial articular surface. The proximal tibial osteotomy index was 18.45-23.35 (mean, 20.46); the distal tibial osteotomy index was 14.36-23.05 (mean, 18.81). The metaphyseal-diaphyseal connection shold be selected in the proximal and distal tibia osteotomy, the lower one third of the tibia is not suitable for ostetomy.
Tosun, Haci Bayram; Agir, Ismail; Gumustas, Seyitali; Serbest, Sancar; Uludag, Abuzer; Celik, Suat
Background There are many techniques that are used for limb lengthening. Lengthening a limb over a plate is an alternative choice used in children or when using an intramedullary nail is difficult. Objectives In this study, we presented a new technique for tibial lengthening using a monolateral external fixator over a lengthening plate. Materials and Methods For tibial lengthening, a monolateral external fixator was attached to the composite bone model medially. After a corticotomy was performed, the lengthening plate was placed laterally. Three locking screws were inserted proximally, and two cortical screws were inserted into a lengthening hole that was 1 cm below the osteotomy site. We avoided contact between the screws of the lengthening plate and the pins of the external fixator. During bone lengthening with the monolateral external fixator, the screws at the lengthening hole were able to slide distally with the distal segment of the tibia to allow for tibial elongation. Two locking screws were fixed at the distal locking holes of the plate when the bone elongation was complete. The external fixator was then removed. Results The fixator-assisted lengthening plate allowed bone lengthening without malalignment. There were no mechanical problems associated with the external fixator during the lengthening process. Plate osteosynthesis was stable after the fixator was removed. There was no contact between the screws of plate and the Schanz pins of the external fixator under C-arm fluoroscopy. Conclusions The fixator-assisted lengthening plate technique helps to maintain the stability and alignment at both sides of an osteotomy during tibial elongation. It allows the early removal of the external fixator immediately after lengthening is completed. This technique can be applied in children with open physes and in patients with a narrow medullary canal who are unsuitable for limb lengthening over an intramedullary nail. PMID:28184364
Gupta, Aditya K; Simpson, Fiona C
The route of antifungal drug entry into the nail plate and the underlying nail bed plays an important role in determining the efficacy of therapy. Oral antifungal agents reach the nail bed and nail plate by being ingested and achieving antifungal levels in the blood stream that are well in excess of the minimum inhibitory concentration. The reticular circulation at the distal end of the digit enables the drug to reach the nail bed, the proximal matrix and the lateral nail folds. The drug then diffuses into the proximal, ventral and lateral nail plate. The primary route of drug delivery for topical lacquers is transungual, with drug applied to the dorsal aspect of the nail plate and penetrating to the underlying nail bed. The new topical agents approved in the US for the treatment of onychomycosis are solutions with lower viscosity and increased nail penetration characteristics; therefore, these agents penetrate through the transungual route, but also through the space between the nail plate and the nail bed. This subungual route is an important method of drug delivery and is able to in part circumvent the thickness of the nail plate.
The distal region of the nail unit, which marks the transition of the nail bed to the hyponychium, is known clinically as the onychodermal band (ODB). For several authors, the ODB is described as 2 subbands of tonal values: slightly milky and pink from proximal to distal. However, its 2 subbands show individual variation and are often scarcely visible. It has been stated that the proximal subband, that is, the white band of Pinkus, corresponds histologically to the attachment of the compact orthokeratotic layer of the hyponychium to the nail plate. In 2 studies, I have individualized a transitional zone between the nail bed and the hyponychium: the nail isthmus. In these previous studies, the ODB was not visible. The purpose of this article is to analyze the anatomo-clinical correlations between the nail isthmus and the ODB and to highlight some new physiological information concerning the nail growth. A case showing clearly the 2 clinical subbands of ODB was investigated. In addition, all the longitudinal sections of the 5 normal nail unit specimens, used in the 2 previous studies, were reviewed to analyze the ventral surface of the nail plate in longitudinal planes. The nail isthmus can be described synthetically by 2 features: (1) a stair-like appearance of the epithelium of the distal nail bed with a marked depression of the epithelium below the inferior surface of the nail plate (2) a specialized mode of attachment of its horny layer to nail plate via a horizontal mode of differentiation. The white band of Pinkus corresponded histologically to the nail isthmus. Its white color was caused by alteration in light diffraction in the thin compartment of pale parakeratotic corneocytes squeezed between the nail plate and the epithelium of the nail isthmus. The pink middle band corresponded to the 2 horny layers surmounting the epidermis of the hyponychium: the compact horny layer of the hyponychium and the thin pale "tongue-like" parakeratotic extension of the nail
The nail is the largest skin appendage. It grows continuously through life in a non-cyclical manner; its growth is not hormone-dependent. The nail of the middle finger of the dominant hand grows fastest with approximately 0.1 mm/day, whereas the big toe nail grows only 0.03-0.05 mm/d. The nails' size and shape vary characteristically from finger to finger and from toe to toe, for which the size and shape of the bone of the terminal phalanx is responsible. The nail apparatus consists of both epithelial and connective tissue components. The matrix epithelium is responsible for the production of the nail plate whereas the nail bed epithelium mediates firm attachment. The hyponychium is a specialized structure sealing the subungual space and allowing the nail plate to physiologically detach from the nail bed. The proximal nail fold covers most of the matrix. Its free end forms the cuticle which seals the nail pocket or cul-de-sac. The dermis of the matrix and nail bed is specialized with a morphogenetic potency. The proximal and lateral nail folds form a frame on three sides giving the nail stability and allowing it to grow out. The nail protects the distal phalanx, is an extremely versatile tool for defense and dexterity and increases the sensitivity of the tip of the finger. Nail apparatus, finger tip, tendons and ligaments of the distal interphalangeal joint form a functional unit and cannot be seen independently. The nail organ has only a certain number of reaction patterns that differ in many respects from hairy and palmoplantar skin.
Flores, Leandro Pretto
The results of surgical repair of the fibular division of the sciatic nerve have been considered unsatisfactory, especially if grafts are necessary to reconstruct the nerve. To consider the clinical application of the concept of distal nerve transfer for the treatment of high sciatic nerve injuries, this study aimed to determine detailed anatomic data about the possible donor branches from the tibial nerve that are available for reinnervation of the deep fibular nerve at the level of the popliteal fossa. An anatomic study was performed that included the dissection of the popliteal fossa in 12 lower limbs of 6 formalin-fixed adult cadavers. It focused on the detailed anatomy of the tibial nerve and its branches at the level of the proximal leg as well as the anatomy of the common fibular nerve and its largest divisions at the level of the neck of the fibula, i.e., the deep and superficial fibular nerves. The branches of the tibial nerve destined to the lateral and medial head of the gastrocnemius had a mean length of 43 mm and 35 mm, respectively. The branch to the posterior soleus muscle had a mean length of 65 mm. Intraneural dissection of the common fibular nerve, isolating its deep and superficial fibular divisions, was possible to a proximal mean distance of 71 mm. A tensionless direct suture to the deep fibular nerve was made possible by using the nerve to the lateral head of the gastrocnemius and the nerve to the posterior soleus muscle in all specimens. Direct suture of the nerve to the medial head of the gastrocnemius was possible in all cases except 1. The nerve to the lateral and medial heads of the gastrocnemius and the nerve to the posterior soleus muscle can be used as donors to restore function of the deep fibular nerve in cases of high sciatic nerve injury. However, proximal intraneural dissection of the deep fibular division of the common fibular nerve must also be performed. We recommend that the nerve to the posterior soleus muscle should be the
... the surface of the nail can be PODIAT PHYSIC filed off, followed by the application of an ... oral medication, and debridement (removal of diseased nail matter and debris) of an infected nail. Newer oral ...
Carr, James B; Williams, Daniel; Richards, Mike
In closed intramedullary nailing of the femur in the lateral decubitus position without the use of a fracture table, access to the proximal femur is enhanced as compared to supine nailing, especially in large patients. The hip is typically flexed during the nailing, which allows the nail to be placed posterior to the gluteus medius, thus minimizing abductor damage. The deforming forces of flexion and abduction in proximal fracture patterns can be readily overcome by this technique. Proper rotation of the leg can be assessed clinically or with the use of a femoral neck anteversion guide wire. Fluoroscopic visualization of the proximal femur is excellent, including the femoral head, thus facilitating reconstruction nailing.
Baran, Robert; Haneke, Eckart
Matricectomy refers to the complete extirpation of the nail matrix, resulting in permanent nail loss. Usually however, matricectomy is only partial, restricted to one or both lateral horns of the matrix. Nail ablation is the definitive removal of the entire nail organ. The most important common denominator in the successful matricectomy is the total removal or destruction of the matrix tissue. Matricectomy may be indicated for the management of onychauxis, onychogryphosis, congenital nail dystrophies, and chronic painful nail, such as recalcitrant ingrown toenail or split within the medial or lateral one-third of the nail.
Maleszka, Romuald; Ratajczak-Stefańska, Violetta; Boer, Magdalena; Kiedrowicz, Magdalena
Clinical symptoms attributed to the nail apparatus and observed in cosmetology include atrophic or hypertrophic lesions, pathologic nail coloration, abnormalities of the nail surface, and disorders of the nail plate and bed junction. These symptoms may reflect pathologic processes limited to the nail apparatus or may be the consequence of a dermal or systemic disease. Even though the etiology of nail lesions is variegated, diseases of the nails are simply classified as infectious or non-infectious. The aim of this work was to present the most common diseases of the nail apparatus encountered in cosmetology. Often, nail diseases worsen the quality of life of the patient. In addition, the variegated symptomatology demonstrates that nail lesions should be viewed in a wider perspective because they often are important signs of pathologic processes taking place in the organism of the patient.
Karaarslan, Ahmet Adnan; Aycan, Hakan; Mayda, Aslan; Ertem, Fatih; Sesli, Erhan
This study aims to investigate which intramedullary nail is biomechanically better for establishing interfragmentary rotational stability. Thirty composite femurs were utilized in this study. We analyzed interfragmentary rotational arc displacements between 10 Nm external-6 Nm internal torques and 6 Nm external-6 Nm internal torques which imitate rotation torques while walking on a flat surface and descending stairs by administering 10 interlocking nails, 10 compression nails, and 10 Mehmet anti-rotation nails with tube compression. Maximum interfragmentary rotation arc displacement between 10 Nm external rotation and 6 Nm internal rotation torques was mean 1.64 mm in the Mehmet nail compressed by 7 Nm torque wrench. This value was lower by 309% (6.72 mm) from interlocking nail (p=0.000), 201% (5.42 mm) from compression nail compressed by 2.5 Nm torque wrench (p=0.000), and 26% (1.92 mm) from compression nail compressed by 7 Nm torque wrench (p>0.05). In axially stable transvers and short oblique femur fractures, Mehmet nail is superior to other intramedullary nails with limited movement between locking screw and hole, more interfragmentary compression without locking screw deformation, and no proximal nail migration.
Roman hihstorian Pliny the Younger noted that Mount Vesuvius blew its top and destroyed Pompeii in the early afternoon of August 24, 1,918 years ago. Now, a team of scientists, tempted by the certainty of that record, has confirmed the eruption to within 7 years. The team developed and used an improved radioactive argon-argon dating technique, which they say can reliably establish the age of rocks as old as the solar system or as recent as 1,000 years old.“We nailed the date to 5% on our first attempt, so we could probably get the error down to 1% or less,” says Paul Renne, adjunct associate professor of geology and geophysics at the University of California at Berkeley and director of the private Berkeley Geochronology Center. “Dating things that are really young has always been the Holy Grail of potassium-argon [an earlier method] and argonargon dating.”
Chiriac, Anca; Brzezinski, Piotr; Foia, Liliana; Marincu, Iosif
Green nails, also known as chloronychia or green nail syndrome, are characterized by green discoloration of the nail plate (greenish-yellow, greenish-brown, greenish-black), proximal chronic non-tender paronychia, and distolateral onycholysis. The cause is Pseudomonas aeruginosa infection of the nail plate in persons whose hands are constantly exposed to water, soaps, and detergents or are subject to mechanical trauma, especially in the elderly. Green or black coloration of the nails should raise suspicion for Pseudomonas infection and be treated with an oral quinolone (ciprofloxacin), particularly in aged patients. We present three cases of green nails in elderly persons.
Chiriac, Anca; Brzezinski, Piotr; Foia, Liliana; Marincu, Iosif
Green nails, also known as chloronychia or green nail syndrome, are characterized by green discoloration of the nail plate (greenish-yellow, greenish-brown, greenish-black), proximal chronic non-tender paronychia, and distolateral onycholysis. The cause is Pseudomonas aeruginosa infection of the nail plate in persons whose hands are constantly exposed to water, soaps, and detergents or are subject to mechanical trauma, especially in the elderly. Green or black coloration of the nails should raise suspicion for Pseudomonas infection and be treated with an oral quinolone (ciprofloxacin), particularly in aged patients. We present three cases of green nails in elderly persons. PMID:25609938
Burghardt, Rolf D.; Yoshino, Koichi; Kashiwagi, Naoya; Yoshino, Shigeo; Bhave, Anil; Paley, Dror; Herzenberg, John E.
Purpose Outcome assessment after double level tibial lengthening in patients with dwarfism. Methods Fourteen patients with dwarfism were analyzed after bilateral simultaneous double level tibial lengthening. Results Average age was 15.1 years. Average lengthening was 13.5 cm. The two levels were lengthened by an average of 7.5 cm proximally and 6.0 cm distally. Concomitant deformities were also addressed during lengthening. External fixation treatment time averaged 8.8 months. Healing index averaged 0.7 months/cm. Conclusion Bilateral tibial lengthening for dwarfism is difficult, but the results are usually quite gratifying. PMID:26566326
Stewart, Campbell L; Rubin, Adam I
Nail unit dermatopathology is a growing field filled with many challenges. Many advances in this field have been made in the last 5 years. This review article provides an update on new information and studies published in that period of time. We divided these works into different sections, including clinical and pathologic challenges in diagnosis and treatment of nail disorders, nail unit biopsy and processing techniques, normal nail unit histology, nail plate structural and growth pathology, metabolic disease, inflammatory conditions, onychomycosis, benign growths, malignant growths, and dyschromias. Specific highlights include advances in the marking and orientation of nail unit biopsies for improved histologic interpretation, improved nail plate softening techniques, new methods for histologic evaluation of onychomycosis, descriptions of newly described benign growths unique to the nail unit, and the morphologic and immunohistochemical distinction between benign and malignant pigmented lesions of the nail unit.
Kojima, Kodi Edson; Ferreira, Ramon Venzon
The long-bone fractures occur most frequently in the tibial shaft. Adequate treatment of such fractures avoids consolidation failure, skewed consolidation and reoperation. To classify these fractures, the AO/OTA classification method is still used, but it is worthwhile getting to know the Ellis classification method, which also includes assessment of soft-tissue injuries. There is often an association with compartmental syndrome, and early diagnosis can be achieved through evaluating clinical parameters and constant clinical monitoring. Once the diagnosis has been made, fasciotomy should be performed. It is always difficult to assess consolidation, but the RUST method may help in this. Radiography is assessed in two projections, and points are scored for the presence of the fracture line and a visible bone callus. Today, the dogma of six hours for cleaning the exposed fracture is under discussion. It is considered that an early start to intravenous antibiotic therapy and the lesion severity are very important. The question of early or late closure of the lesion in an exposed fracture has gone through several phases: sometimes early closure has been indicated and sometimes late closure. Currently, whenever possible, early closure of the lesion is recommended, since this diminishes the risk of infection. Milling of the canal when the intramedullary nail is introduced is still a controversial subject. Despite strong personal positions in favor of milling, studies have shown that there may be some advantage in relation to closed fractures, but not in exposed fractures.
Kojima, Kodi Edson; Ferreira, Ramon Venzon
The long-bone fractures occur most frequently in the tibial shaft. Adequate treatment of such fractures avoids consolidation failure, skewed consolidation and reoperation. To classify these fractures, the AO/OTA classification method is still used, but it is worthwhile getting to know the Ellis classification method, which also includes assessment of soft-tissue injuries. There is often an association with compartmental syndrome, and early diagnosis can be achieved through evaluating clinical parameters and constant clinical monitoring. Once the diagnosis has been made, fasciotomy should be performed. It is always difficult to assess consolidation, but the RUST method may help in this. Radiography is assessed in two projections, and points are scored for the presence of the fracture line and a visible bone callus. Today, the dogma of six hours for cleaning the exposed fracture is under discussion. It is considered that an early start to intravenous antibiotic therapy and the lesion severity are very important. The question of early or late closure of the lesion in an exposed fracture has gone through several phases: sometimes early closure has been indicated and sometimes late closure. Currently, whenever possible, early closure of the lesion is recommended, since this diminishes the risk of infection. Milling of the canal when the intramedullary nail is introduced is still a controversial subject. Despite strong personal positions in favor of milling, studies have shown that there may be some advantage in relation to closed fractures, but not in exposed fractures. PMID:27026999
Popp, Andrew Damian; Kulenovic, Indira; Kulenovic, Elvedin
A 45 year old male presented to a primary care physician with complaints of long term, bilateral knee and bilateral foot pain, without history of significant trauma. Physical exam demonstrated full range of motion without any erythema or edema. Fingernails were abnormal and hypoplastic. Bilateral knee radiographs demonstrated moderate degenerative changes of the right knee. Small, atrophic patellae were noted to be proximal to their expected location. Two months later the patient returned to his primary care physician for worsening of the knee pain related to cooler outside temperatures. An NSAID had initially relieved the pain but was becoming less and less efficacious. Alternative medications were prescribed to better control the pain. Complaints of continued knee pain and now bilateral hip pain brought him back to his physician four months later. He requested a referral to an orthopedic surgeon and an MR of the right knee was obtained. The finding showed complex tear of the lateral meniscus in patient with Nail Patella Syndrome.
While intramedullary nailing has been established as the treatment of choice for diaphyseal fractures of the femur and tibia, its role in the management of diaphyseal humeral fractures remains controversial. The reasons include not only the complicated anatomy and unique biomechanical characteristics of the arm but also the fact that surgical technique and nail designs devised for the treatment of femoral and tibial fractures are being transposed to the humerus. As a result there is no consensus on many aspects of the humeral nailing procedure, e.g., the basic nail design, nail selection criteria, timing of the procedure, and the fundamental principles of the surgical technique (e.g., antegrade/retrograde, reamed/unreamed, and static/dynamic). These issues will be analyzed and discussed in the present article. Proposals aiming to improve outcomes include the categorization of humeral nails in two distinct groups: “fixed” and “bio”, avoidance of reaming for the antegrade technique and utilization of “semi-reaming” for the retrograde technique, guidelines for reducing complications, setting the best “timing” for nailing and criteria for selecting the most appropriate surgical technique (antegrade or retrograde). Finally, suggestions are made on proper planning and conducting clinical and biomechanical studies regarding the use of intramedullary nailing in the management of humeral shaft fractures. PMID:21559099
Jo, Ho-Seung; Park, Jin-Sung; Byun, June-Ho; Lee, Young-Bok; Choi, Young-Lac; Cho, Seong-Hee; Moon, Dong-Kyu; Lee, Sang-Hyuk; Hwang, Sun-Chul
The purpose of this study was to determine the standard hinge position to minimize effects from medial open-wedge high tibial osteotomy (HTO) on the posterior tibial slope. Sixteen cadaveric knees underwent medial open-wedge osteotomy using either the standard or the low hinge position. To define the standard hinge position, a line 3 cm inferior to the medial tibial plateau towards the fibular head and located its intersection with a longitudinal line 1 cm medial to the fibular shaft was drawn. Low hinge position was defined as the point 1 cm inferior to the standard position. After tibial osteotomy, computed tomography scans of each knee were taken and three-dimensional models were constructed to characterize hinge position orientation and measure the osteotomy site effects on posterior tibial slope, medial proximal tibial angle, and gap ratio (the ratio of the anterior to posterior gap in the opened wedge). In two low hinge position specimens, the tibial lateral cortex hinge fracture occurred. Osteotomy through the low hinge position resulted in significantly greater posterior tibial slope compared to the standard hinge position (mean ± standard deviation) (11.2 ± 3.0° and 5.6 ± 2.5°, respectively; p < 0.001). Medial proximal tibial angle was also significantly greater for low compared to standard hinge position (95.4 ± 3.5° and 88.0 ± 3.5°, respectively; p < 0.001). Gap ratio was not significantly different between the two groups. Hinge position significantly affects the posterior tibial slope and medial proximal tibial angle following medial open-wedge HTO. Accurate hinge position is crucial to prevent complications from changes in posterior tibial slope and medial proximal tibial angle after surgery.
Estes, Chris; Rhee, Peter; Shrader, M Wade; Csavina, Kristine; Jacofsky, Marc C; Jacofsky, David J
The purpose of this study was to compare the biomechanical properties of a contoured locking plate instrumented with either an all-locked or hybrid locked/nonlocked screw construct in a proximal metaphyseal fracture of the tibia (AO 41-A3.2). A standardized proximal metaphyseal wedge osteotomy (AO 41-A3.2) was created in five pairs of cadaveric tibia. Each pair was randomly instrumented with either an all-locked or combination locked/nonlocked screw construct using a locked contoured periarticular plate (Peri-Loc periarticular locked plating system, Smith & Nephew, Memphis, TN). Vertical subsidence (irreversible deformation) and deflection (reversible deformation) in each pair were analyzed and compared. Load to failure, defined by complete fracture gap closure, was also determined. There was no statistically significant difference in vertical subsidence (P = 0.19) or deflection (P = 0.19) of the proximal tibia between the all-locked and combination locked/nonlocked screw construct with increasing levels of cyclical axial load from 200 to 1200 N. Failure occurred at a mean value of 2160 N in the locked group and 1760 N in the hybrid group (P = 0.19); the failure mode was plate bending in all specimens. The results indicate that the use of compression screws with locked screws in this particular construct allows a similar amount of irreversible and reversible deformation in response to an axial load when compared to an all-locked screw construct. This suggests that there is no statistically significant difference in the stability in fixation between the two methods, allowing the surgeon the freedom to choose the appropriate screw combination unique to each fracture.
Oh, Chi Hun; Yi, Ju Won
We report on three cases of subtrochanteric femoral fractures during trochanteric intramedullary nailing for the treatment of femoral shaft fractures. Trochanteric intramedullary nails, which have a proximal lateral bend, are specifically designed for trochanteric insertion. When combined with the modified insertion technique, trochanteric intramedullary nails reduce iatrogenic fracture comminution and varus malalignment. We herein describe technical aspects of trochanteric intramedullary nailing for femoral shaft fractures to improve its application and prevent implant-derived complications. PMID:24009910
By mechanical definition an intramedullary nail is not a nail but rather a bendable feather, subject to longitudinal tension and to a lesser degree to transverse pressure. Reaming the medullary canal is necessary for centralization of the nail as well as to increase the area of contact with the bone. However, this procedure is detrimental to the bone metabolism and reduces its elasticity against torsional forces. The dynamic locking nail-system is more biologic than conventional nailing and it reduces rotatory instability with the help of additional components, such as transverse screws. Only static locking allows true static weight bearing with crutches, but not dynamic mobilisation. Nails with conventional strength and in leaf of trefoil formation are superior to other designs. However, an improved angle in the proximal locking is suggested, as this would allow for a three to four times greater weight bearing.
... treatment is to apply lotions containing alpha-hydroxy acids or lanolin containing lotions such as "Elon" (by the "Dartmouth" company) to the nails after first soaking nails in water for 5 minutes. Wearing gloves when performing household ...
... Drug, or Both? (Or Is It Soap?)". By law, nail products sold in the United States must ... only" (see Cosmetic Labeling: An Overview ). Under the law, cosmetic products and ingredients, including nail products, do ...
Jalgaonkar, Azal A; Dachepalli, Sunil; Al-Wattar, Zaid; Rao, Sudhir; Kochhar, Tony
Avulsion fractures of the tibial tuberosity are typically sustained by adolescent males during sporting activities. Tibial tuberosity avulsions with simultaneous proximal tibial epiphyseal fractures are rare injuries. We present an unusual case of Ogden type IIIA avulsion fracture of tibial tuberosity with a Salter Harris type IV posterior fracture of proximal tibial epiphysis in a 13-year-old boy. We believe that the patient sustained the tibial tuberosity avulsion during the take-off phase of a jump while playing basketball due to sudden violent contraction of the quadriceps as the knee was extending. This was then followed by the posterior Salter Harris type IV fracture of proximal tibial physis as he landed on his leg with enormous forces passing through the knee. Although standard radiographs were helpful in diagnosing the complex fracture pattern, precise configuration was only established by computed tomography (CT) scan. The scan also excluded well-recognized concomitant injuries including ligament and meniscal injuries. Unlike other reported cases, our patient did not have compartment syndrome. Anatomic reduction and stabilization with a partially threaded transepiphyseal cannulated screw and a metaphyseal screw followed by early mobilization ensured an excellent recovery by the patient.Our case highlights the importance of vigilance and a high index of suspicion for coexisting fractures or soft tissue injuries when treating avulsion fractures of tibial tuberosity. A CT scan is justified in such patients to recognize complex fracture configurations, and surgical treatment should be directed appropriately to both the fractures followed by early rehabilitation. Patients with such injuries warrant close monitoring for compartment syndrome during the perioperative period.
Wang, Joon Ho; Bae, Ji Hoon; Lim, Hong Chul; Shon, Won Yong; Kim, Cheol Woong; Cho, Jae Woo
High tibial osteotomy can affect the posterior tibial slope in the sagittal plane because of the triangular configuration of the proximal tibia. However, the effect of the location of cortical hinge on posterior tibial slope has not been previously described. Posterolateral location of the cortical hinge will increase posterior tibial slope after medial open wedge osteotomy, and lateral location of the cortical hinge will not affect the change of the posterior tibial slope. Controlled laboratory study. We performed incomplete valgus open wedge osteotomy on 12 paired knees of 6 fresh-frozen human cadavers (age, 63.4 + or - 7.5 years) using an OrthoPilot navigation system. The left and right legs of each specimen were randomly assigned to a posterolateral (group A) or a lateral (group B) cortical hinge group. Changes in mean medial proximal tibial angle, posterior tibial slope, and opening wedge angle were measured and compared after surgery. In group A, mean medial proximal tibial angle changed from 84.37 degrees + or - 2.8 degrees to 93.48 degrees + or - 3.06 degrees (P = .028); mean posterior tibial slope increased significantly from 8.71 degrees + or - 0.81 degrees to 12.16 degrees + or - 0.84 degrees (P = .031); and mean wedge angle was 1.92 degrees + or - 0.46 degrees . In group B, mean medial proximal tibial angle changed from 82.98 degrees + or - 2.53 degrees to 90.89 degrees + or - 3.25 degrees (P = .027); mean posterior tibial slope changed from 9.19 degrees + or - 1.11 degrees to 9.78 degrees + or - 1.27 degrees (P = .029); and mean wedge angle was 7.25 degrees + or - 0.72 degrees . The location of the intact cortical hinge affects the posterior tibia slope. During medial open wedge osteotomy, the change of posterior tibial slope was larger in the posterolateral than in the lateral cortical hinge group. To prevent the unintentional increase of the posterior tibial slope, special attention should be paid to locate the intact cortical hinge on the lateral
Hinterwimmer, Stefan; Beitzel, Knut; Paul, Jochen; Kirchhoff, Chlodwig; Sauerschnig, Martin; von Eisenhart-Rothe, Rüdiger; Imhoff, Andreas B
Valgus-producing open-wedge high tibial osteotomy is an established treatment for varus malalignment and medial osteoarthritis, with reproducible results in the frontal plane. However, an undesirable but often accepted increase in posterior tibial slope and decrease in patellar height are still routinely seen. To evaluate the influence of valgus open-wedge high tibial osteotomy on posterior tibial slope and patellar height when special techniques are used to minimize unwanted changes. Case series; Level of evidence, 4. Twenty-five patients, 3 women and 22 men (mean age, 40.2 years), underwent valgus open-wedge high tibial osteotomy. Several technical steps were taken to prevent an increase in posterior tibial slope during the osteotomy. To minimize patellar height changes, the tibial tuberosity was left on either the proximal or distal fragment, depending on the desired patellofemoral effect. The medial and lateral posterior slope was measured using the proximal posterior cortex as a reference; the patellar height was assessed with the Caton-Deschamps Index and compared on preoperative and postoperative radiographs. No significant posterior tibial slope changes were observed. Patellar height increased with both types of tibial tuberosity osteotomy. With the proximal osteotomy, the Caton-Deschamps Index increased from 0.95 to 0.97; with the distal osteotomy, it increased from 0.89 to 0.95. The change was not significant with either osteotomy. The posterior tibial slope did not change on the medial side, measuring 4.2 preoperatively and postoperatively. The lateral slope decreased from 5.4 to 5.1. There was no correlation between the correction in the coronal plane and the changes in the sagittal plane. Open-wedge high tibial osteotomy can be performed without significant changes in patellar height or posterior tibial slope if specific intraoperative methods are used to prevent their occurrence. Analysis and control of sagittal changes in valgus open-wedge high
Borkowski, Leszek; Pawłowska, Marta; Radzki, Radosław P; Bieńko, Marek; Polkowska, Izabela; Belcarz, Anna; Karpiński, Mirosław; Słowik, Tymoteusz; Matuszewski, Łukasz; Ślósarczyk, Anna; Ginalska, Grażyna
A novel elastic hydroxyapatite-based composite of high surgical handiness has been developed. Its potential application in orthopedics as a filler of bone defects has been studied. The biomaterial was composed of carbonated hydroxyapatite (CHAP) granules and polysaccharide polymer (β-1,3-glucan). Cylinders of 4mm in diameter and 6mm in length were implanted into bone cavities created in the proximal metaphysis of tibiae of 24 New Zealand white rabbits. 18 sham-operated animals were used as controls. After 1, 3 or 6 months, the rabbits were euthanized, the bones were harvested and subjected to analysis. Radiological images and histological sections revealed integration of implants with bone tissue with no signs of graft rejection. Peripheral quantitative computed tomography (pQCT) indicated the stimulating effect of the biomaterial on bone formation and mineralization. Densitometry (DXA) analysis suggested that biomineralization of bones was preceded by bioresorption and gradual disappearance of porous ceramic granules. The findings suggest that the CHAP-glucan composite material enables regeneration of bone tissue and could serve as a bone defect filler. Copyright © 2015 Elsevier B.V. All rights reserved.
Levine, A H; Pais, M J; Berinson, H; Amenta, P S
An unusually prominent soleal line (a normal anatomic variant) may mimic periosteal reaction along the posterior margin of the proximal tibial shaft. This area of pseudoperiostitis is differentiated from hyperostoses arising from the anterior tibial tubercle and the interosseous membrane. It is always associated with normal, undisturbed architecture of the underlying bone.
Meng, W Z; Guo, Y J; Liu, Z K; Li, Y F; Wang, G Z
Objective: To investigate the influencing factors for trauma-induced tibial infection in underground coal mine. Methods: A retrospective analysis was performed for the clinical data of 1 090 patients with tibial fracture complicated by bone infection who were injured in underground coal mine and admitted to our hospital from January 1995 to August 2015, including the type of trauma, injured parts, severity, and treatment outcome. The association between risk factors and infection was analyzed. Results: Among the 1 090 patients, 357 had the clinical manifestations of acute and chronic bone infection, 219 had red and swollen legs with heat pain, and 138 experienced skin necrosis, rupture, and discharge of pus. The incidence rates of tibial infection from 1995 to 2001, from 2002 to 2008, and from 2009 to 2015 were 31%, 26.9%, and 20.2%, respectively. The incidence rate of bone infection in the proximal segment of the tibia was significantly higher than that in the middle and distal segments (42.1% vs 18.9%/27.1%, P<0.01) . As for patients with different types of trauma (Gustilo typing) , the patients with type III fracture had a significantly higher incidence rate of bone infection than those with type I/II infection (52.8% vs 21.8%/24.6%, P<0.01) . The incidence rates of bone infection after bone traction, internal fixation with steel plates, fixation with external fixator, and fixation with intramedullary nail were 20.7%, 43.5%, 21.4%, and 26.1%, respectively, suggesting that internal fixation with steel plates had a significantly higher incidence rate of bone infection than other fixation methods (P<0.01) . The multivariate logistic regression analysis showed that the position of tibial fracture and type of fracture were independent risk factors for bone infection. Conclusion: There is a high incidence rate of trauma-induced tibial infection in workers in underground coal mine. The position of tibial fracture and type of fracture are independent risk factors for
Palliyil, Biji B; Li, Cong; Owaisat, Suzan; Lebo, David B
The main objective of the current work is to demonstrate the process of passive lateral diffusion in the human nail plate and its effect on the passive transungual permeation of antifungal drug ciclopirox olamine (CPO). A water soluble dye, methyl red sodium salt (MR) was used to visualize the process of lateral diffusion using a novel suspended nail experiment. The decline in concentration of CPO correlates with that of concentration of MR from the proximal to the distal end of the nail in suspended nail study. Three toenails each were trimmed to 5 mm × 5 mm (25 mm(2)), 7 mm × 7 mm (49 mm(2)), and 9 mm × 9 mm (81 mm(2)) to study the extent and effect of lateral diffusion of the CPO on its in vitro transungual permeation. The permeation flux of CPO decreased as the surface area of the toenail increased. There was a positive correlation between the concentrations of CPO and MR in the area of application and in the peripheral area of the toenails of the three surface areas, confirming the findings in the suspended nail experiment. Profound lateral diffusion of CPO was demonstrated and shown to reduce the in vitro passive transungual drug permeation and prolong the lag-time in human toenails. The study data implies that during passive in vitro transungual permeation experiments, the peripheral nail around the area of drug application has to be kept to a minimum, in order to get reliable data which mimics the in vivo situation.
Lonner, J H; Lotke, P A
Spontaneous osteonecrosis of the tibial plateau involves a continuum of change observed in the subchondral zone that is commonly associated with early and mid stages of osteoarthritis. The typical patient is an elderly woman who experiences a sudden onset of pain in the medial aspect of the knee. The diagnosis of this under-appreciated clinical entity may be difficult, but careful examination and judicious use of imaging studies, as well as a high index of suspicion, may facilitate the accurate diagnosis. Although the radiographs may initially be normal (with the exception of mild arthrosis), radionuclide scans and MRI can be of great value. The MRI studies usually show a decreased signal intensity on a T1-weighted image, but may be normal in the early course of the disease. The T2-weighted images and fat suppression views are helpful in establishing a diagnosis and determining the extent of involvement. Recognition of this problem may help to avoid unnecessary intra-articular surgery. Many of these patients have complete or partial resolution of symptoms by 1 year, after a period of protected weight bearing. Nonetheless, surgery may be necessary for more advanced lesions and in those patients with progressive arthrosis.
Shin, Young-Soo; Han, Seung-Beom; Hwang, Yeok-Ku; Suh, Dong-Won; Lee, Dae-Hee
We aimed to compare posterior cruciate ligament (PCL) tibial tunnel location after tibial guide insertion medial (between the PCL remnant and the medial femoral condyle) and lateral (between the PCL remnant and the anterior cruciate ligament) to the PCL stump as determined by in vivo 3-dimensional computed tomography (3D-CT). Tibial tunnel aperture location was analyzed by immediate postoperative in vivo CT in 66 patients who underwent single-bundle PCL reconstruction, 31 by over-the-PCL and 35 by under-the-PCL tibial guide insertion techniques. Tibial tunnel positions were measured in the medial to lateral and proximal to distal directions of the posterior proximal tibia. The center of the tibial tunnel aperture was located more laterally (by 2.7 mm) in the over-the-PCL group than in the under-the-PCL group (P = .040) and by a relative percentage (absolute value/tibial width) of 3.2% (P = .031). Tibial tunnel positions in the proximal to distal direction, determined by absolute value and relative percentage, were similar in the 2 groups. Tibial tunnel apertures were located more laterally after lateral-to-the-PCL tibial guide insertion than after medial-to-the-PCL tibial guide insertion. There was, however, no significant difference between these techniques in distance from the joint line to the tibial tunnel aperture. Insertion lateral to the PCL stump may result in better placement of the PCL in its anatomic footprint. Level III, retrospective comparative study. Copyright © 2015 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.
Clement, N. D.; Tawonsawatruk, T.; Simpson, C. J.; Simpson, A. H. R. W.
Objectives The radiographic union score for tibial (RUST) fractures was developed by Whelan et al to assess the healing of tibial fractures following intramedullary nailing. In the current study, the repeatability and reliability of the RUST score was evaluated in an independent centre (a) using the original description, (b) after further interpretation of the description of the score, and (c) with the immediate post-operative radiograph available for comparison. Methods A total of 15 radiographs of tibial shaft fractures treated by intramedullary nailing (IM) were scored by three observers using the RUST system. Following discussion on how the criteria of the RUST system should be implemented, 45 sets (i.e. AP and lateral) of radiographs of IM nailed tibial fractures were scored by five observers. Finally, these 45 sets of radiographs were rescored with the baseline post-operative radiograph available for comparison. Results The initial intraclass correlation (ICC) on the first 15 sets of radiographs was 0.67 (95% CI 0.63 to 0.71). However, the original description was being interpreted in different ways. After agreeing on the interpretation, the ICC on the second cohort improved to 0.75. The ICC improved even further to 0.79, when the baseline post-operative radiographs were available for comparison. Conclusion This study demonstrates that the RUST scoring system is a reliable and repeatable outcome measure for assessing tibial fracture healing. Further improvement in the reliability of the scoring system can be obtained if the radiographs are compared with the baseline post-operative radiographs. Cite this article: Mr J.M. Leow. The radiographic union scale in tibial (RUST) fractures: Reliability of the outcome measure at an independent centre. Bone Joint Res 2016;5:116–121. DOI: 10.1302/2046-3758.54.2000628. PMID:27073210
Garnavos, C; Lunn, P G
The early clinical results of humeral nailing using a fluted intramedullary nail with a locking screw are reported. The True-Flex nail has been designed with a proximal cancellous screw to prevent 'back-tracking' and with flutes to give rotational control. The design features have proved to be successful in the authors' brief clinical experience in 12 patients with complicated fractures, non-unions or pathological lesions. Eight of the 10 fractures healed uneventfully, one by delayed union; one had to be revised because of loosening due to use of a nail which was too narrow. There were no serious complications. Return of function in the arm was good. This humeral nail may be suitable for fixation of some complicated and difficult fractures and lesions of the humeral shaft.
Darouiche, R O; Farmer, J; Chaput, C; Mansouri, M; Saleh, G; Landon, G C
The coating of medical devices with antimicrobial agents has recently emerged as a potentially effective method for the prevention of device-related infections. We examined the anti-infective efficacy of intramedullary nails coated with an antiseptic combination of chlorhexidine and chloroxylenol in a rabbit model of device-related infection after fixation of an open tibial fracture. The rabbits were randomized to receive 2.8-by-100-millimeter stainless-steel tibial intramedullary nails that either were uncoated or were coated with antiseptic. After administration of anesthesia and preoperative antibiotic prophylaxis, a tibial fracture was created and then reduced with insertion of the intramedullary nail. A bacterial inoculum of 10(6) colony-forming units of Staphylococcus aureus was injected into the intramedullary canal, and the wound was sutured. Radiographs of the tibiae were made postoperatively, and the rabbits were monitored daily. They were killed at six weeks, or earlier if there was dehiscence of the wound, the fracture became grossly unstable, or the rabbit failed to thrive. The use of the antiseptic-coated nails was associated with a significantly lower rate of device-related osteomyelitis (two of twenty-two; 9 per cent) than the use of the uncoated nails (thirteen of twenty-one; 62 per cent) (p = 0.0003). The radiographic and histopathological findings were generally similar in the two groups of rabbits. Antiseptic agents were not detected in serum. The results suggest that antiseptic-coated fracture-fixation devices provide significant local protection against Staphylococcus aureus, which is the most common cause of infections related to orthopaedic devices.
Optimizing the value of the posterior condylar offset, proximal tibial resection and slope in order to achieve the right balance of the posterior cruciate ligament - clinical application of the molding function of the two parts of the PCL
Bogojevski, Ljubomir; Doksevska, Milena Bogojevska
Introduction: In order to achieve the right balance of the posterior cruciate ligament using the skeletal method is very difficult, almost impossible (Mahoney). Our hypothesis for the right balance of the PCL by using the skeletal method is based on several defined facts: - PCL is a union based of two anatomically independent, but functionally synergic parts, posteromedial and anterolateral part. - The length of the posteromedial part of the PCL is determined by the belonging of the medial compartment and is shortest in varus and longest in valgus deformation. - The length of the anterolateral part of the PCL, placed centrally is unchangeable (cca 38 mm) in every knee and is independent from the anatomical appearance (deformation). - The cylindrical shape of the distal posterior part of the femur (Ficat) depends of the molding function of the PCL (Kapandji) and is a result of the proportion of the both parts of the PCL that is consisted of: shorter posteromedial part, less bone stock on the medial and more bone stock on the lateral condyle (varus knee) and vice versa, longer posteromedial part, more bone stock on the medial condyle and less on the lateral (valgus knee). According to that, the neutral bone stock is achieved by equalization of the lengths of the two parts (common radius of the cylinder) of the PCL, that is basis for the interligamentary balance of the posterior cruciate ligament. Methods: The basic characteristics of the interligamentary balance of the PCL that we started in 2008 are the following: 1. Posterior condylar offset is equal to the even length of the both part of the PCL. 2. Decrease of the values of proximal tibial resection from 10 in varus to 4-6 in valgus. 3. Femoral valgus cut from 6 in excessive varus deformity to 4 in valgus. Results: The clinical evaluation of the cases divided in groups excessive varus, mean varus, valgus type 1, 2 (Krakow) showed right distribution in the groups of the postoperative ROM and intraoperative
Marí, R; Vilamala, D Valverde; García, A León; Guirro, P; López, F Marqués
Introduction: The use of the Kuntscher nail has been the most important advancement in trauma surgery. One of the problems is the difficulty to remove it. A new extraction technique is described in the present case report. Case Report: A 46-year-old man was referred for hip osteoarthritis. He had an acetabulum fracture and a femoral shaft fracture treated 30 years ago with a reamed Kuntscher femoral nail. Lateral hip approach was performed and after attempting to remove the nail with the specific tools being unsuccessful we decided to be more aggressive. Firstly, we performed a simple unicortical osteotomy on the lateral side from the proximal part to below the callus in order to decompress the femoral canal without success. Secondly, a trench in the greater trochanter around the proximal hole was performed to hit the nail from below which was still insufficient and furthermore, the hole broke when hitting the nail so we needed to drill a new hole distally. Finally, the Kuntscher nail was removed. Several cerclages closed the osteotomy and a bone graft was used to close the trench. The patient had a good evolution at one year of follow-up. Conclusion: With this case report, we present a new salvage technique to remove an incarcerated Kuntscher nail when all the described methods have failed. PMID:28116256
Bet, Diego Leonardo; dos Reis, Ana Lucia; Chiacchio, Nilton Di; Belda Junior, Walter
Mycological examination is still the cornerstone for the diagnosis of onychomycosis for many dermatologists, but sampling technique interferes on its sensitivity and specificity. Nail abrasion may be used to reach the most proximal part of the lesion and can be easily accomplished with an electric abrasor. We suggest nail plate dermoscopy to identify the best location for localized abrasion to obtain adequate samples for mycological examination. PMID:26734877
Kempegowda, Harish; Maniar, Hemil H; Richard, Raveesh; Tawari, Akhil; Jove, Graham; Suk, Michael; Beebe, Michael J; Han, Chris; Tornetta, Paul; Kubiak, Erik N; Horwitz, Daniel S
The purpose of this study was to evaluate posterior malleolar injuries associated with nailed tibial fractures and to determine the quality of reduction based on the sequence of fixation in associated fracture patterns. Retrospective cohort study. 1113 tibia fractures treated with an intramedullary nail at 3 level I trauma centers. Tibial shaft fractures with posterior malleolar injury were analyzed regarding type of fracture, mechanism of injury, energy of injury, fracture characteristic, surgical characteristics including sequence of fixation, obvious intraoperative displacement of the posterior malleolar fragment, and the quality of reduction. One group ("malleolus-first") consisted of patients in whom the posterior malleolus was fixed before tibial nailing and the other group ("tibia-first") included patients in whom tibial nailing was done before posterior malleolus fixation. Intraoperative displacement, quality of reduction. Ninety-six of 1113 (9%) nailed tibial shaft fracture patients had a concomitant posterior malleolus fracture (9%). Of the 96 posterior malleolar fracture patients, 70 patients were operatively treated (73%). In the malleolus-first group (54 patients), intraoperative displacement of the posterior malleolar fragment was observed in 1 patient, and 1 case of poor reduction of the posterior malleolar fragment was observed (2%). In the tibia-first group (16 patients), obvious intraoperative displacement of the posterior malleolar fragment was observed in 5 patients (31%), and poor reduction of the posterior malleolar fragment was observed in 7 patients (44%). These percentages of patients with poor quality of reduction were statistically significantly different (p ≤ 0.01). Many low-energy tibia fractures with a spiral configuration do have an associated posterior malleolus fracture. In order to avoid intraoperative displacement and poor reduction, we recommend fixation of the posterior malleolar fragment before nailing of the tibia in
Klein, Scott A; Nyland, John; Caborn, David N M; Kocabey, Yavuz; Nawab, Akbar
Adequate tibial bone mineral density (BMD) is essential to soft tissue graft fixation during anterior cruciate ligament (ACL) reconstruction. The purpose of this study was to compare volumetric bone plug density measurements at the tibial region of interest for ACL reconstruction using a standardized immersion technique and Archimedes' principle. Cancellous bone cores were harvested from the proximal, middle, and distal metaphyseal regions of the lateral tibia and from the standard tibial tunnel location used for ACL reconstruction of 18 cadaveric specimens. Proximal tibial cores displayed 32.6% greater BMD than middle tibial cores and 31.8% greater BMD than distal tibial cores, but did not differ from the BMD of the tibial tunnel cores. Correlational analysis confirmed that the cancellous BMD in the tibial tunnel related to the cancellous BMD of the proximal and distal lateral tibial metaphysis. In conjunction with its adjacent cortical bone, the cancellous BMD of the region used for standard tibial tunnel placement provides an effective foundation for ACL graft fixation. In tibia with poor BMD, bicortical fixation that incorporates cortical bone from the distal tibial tunnel region is recommended.
Feibel, Robert J; Uhthoff, Hans K
Ankle arthrodesis in a plantigrade position. In high-energy open injuries with segmental bone loss: proximal tibial metaphyseal corticotomy with distal Ilizarov bone transport for compensation of leg length discrepancy. Posttraumatic loss of the tibial plafond, usually resulting from open fracture type IIIC. Ipsilateral foot injuries impairing ambulation after fusion. Severe injury to the posterior tibial nerve with absent plantar sensation. Soft-tissue injury not manageable surgically. Inadequate patient compliance. Advanced age. Severe osteoporosis. Acute infection. Standard technique: anteromedial longitudinal incision. Removal of remaining articular cartilage. Passing of Ilizarov wires through the distal fibula, talar neck and body. Placement of 5-mm half-pins through stab incisions, perpendicular to the medial face of the tibial shaft. A lateral to medial 1.8-mm Ilizarov wire in the proximal tibial metaphysis is optional. Callus distraction/Ilizarov bone transport: exposure through an anteromedial incision or transverse traumatic wound. Removal of small residual segment of tibial plafond blocking transport. Retain small vascularized bone fragments not blocking transport. For Ilizarov external fixation, two rings in the proximal tibial region. Drill osteoclasis of the tibial metaphysis 1 cm distal to the tibial tuberosity and complete with Ilizarov osteotome. Secure the Ilizarov threaded rods or clickers. Weight bearing as tolerated. Begin distraction 14 days after corticotomy at a rate of 0.5-1 mm per day depending on patient's age. After docking: Ilizarov ankle arthrodesis. Between January 1993 and September 1996, four patients (two men, two women) with severe, nonreconstructable fractures of the tibial plafond were treated. Callus distraction and Ilizarov bone transport in three patients. Age range 19-68 years (average age 45.7 years). Mean follow-up 6.6 years (4 years 9 months to 7 years 4 months). Average duration of the entire treatment in external
The knowledge of manicure techniques and nail cosmetics compositions are a prerequisite to the understanding of their potential side effects. The brittle nail syndrome is a common problem that roughly affect 20% of women. We will review the etiologic hypothesis, describe the various presentations, and suggest a treatment for this perplexing problem.
Medial tibial stress syndrome is characterised by complaints along the posteromedial tibia. Runners and athletes involved in jumping activities may develop this syndrome. Increased stress to stabilize the foot especially when excessive pronation is present explain the occurrence this lesion.
Ouyang, Xiao; Wang, Jing Rong; Hong, Shi Dong; Xin, Feng; Wang, Lin; Yang, Xiao Wei; Wang, Jian
The aim of this study is to evaluate interlocking intramedullary nails in the treatment of fractures. We retrospectively reviewed 68 adult patients (for a total of 95 fractures) with isolated long-bone fractures who were treated with interlocking intramedullary nails between January 2010 and January 2012. The patients were followed for 18 months to observe the healing of the fracture, time, and the occurrence of complications in the shoulder, knee, and hip joint functions. After about a follow-up period of 26.2 months (range 18-39 months), all cases obtained bony union. The mean time to fracture union was 5.2 months. Cases of knees and hip joint functions of the femoral or tibial fracture and shoulder functions of the humeral fractures were observed. The interlocking intramedullary nails may be considered as an alternative method for isolated diaphyseal fractures of the extremities. The advantages of this method include small operative scars, reliable fixations, better fracture healings, and fewer complications.
Vergara-Amador, E; Davalos Herrera, D; Moreno, L Á
Few studies have evaluated the radiologic characteristics of the development of the anterior tibial tuberosity. This study aimed to evaluate the radiologic characteristics of the anterior tibial tuberosity in a pediatric population broken down into age groups. We assessed 210 plain-film X-rays of the knee from patients aged from 10 to 17 years, divided into groups according to age and sex, for the presence of ossification of the anterior tibial tuberosity, the distance between the anterior tibial tuberosity and the metaphysis, and fusion with the epiphysis. At 10 years of age, the anterior tibial tuberosity was ossified in 50% of the girls but in only 25% of the boys. In all the girls, the anterior tibial tuberosity was ossified at 11 years, fusion of the anterior tibial tuberosity with the epiphysis had started at 12 years, and fusion was complete by 17 years. In boys, the process is delayed by one year compared to girls. A single center of ossification was found in all cases. The ossification of the anterior tibial tuberosity starts distally, then the proximal part fuses with the rest of the epiphysis, and finally the distal part fuses with the tibia. The results of this study help enable a better analysis of the anterior tibial tuberosity in cases of knee pain. Copyright © 2016 SERAM. Publicado por Elsevier España, S.L.U. All rights reserved.
Noh, Jung Ho; Yoon, Kyoung Ho; Song, Sang Jun; Roh, Young Hak; Lee, Jae Woo
The outcomes of posterior cruciate ligament reconstruction may be negatively affected by insufficient tibial tunnel fixation due to relatively lower bone density of the proximal tibia. We introduce a new technique of tibial fixation for posterior cruciate ligament reconstruction using free tendon Achilles allograft that is less affected by the bone density of the tibial metaphysis. PMID:25973367
Shin, Hyun-Tae; Jang, Kee-Taek; Mun, Goo-Hyun; Lee, Dong-Youn; Lee, Jason B
Subungual melanoma is a rare subtype of melanoma that usually originates and spreads from the nail matrix. Because of its poor prognosis and short matrix-to-bone distance, amputation has been traditionally performed. Recently, conservative surgery has been attempted for early subungual melanoma, but the evidence supporting this practice is sparse. As little is known about the progression pattern of subungual melanoma, further advances on the subject may provide better guidance on the optimal surgical approach. Histopathology slides, clinical records, and photographs of 23 cases of subungual melanoma were reviewed. For all cases, each area of the nail unit-proximal nail fold, nail matrix, nail bed, and/or hyponychium-in longitudinal sections was available for histological examination. Growth pattern, dermal invasion, and thickness were assessed in each area of the nail unit. There were five cases of melanoma in situ. Eighteen cases showed dermal invasion in at least one area of the nail unit. There were no cases showing dermal invasion in the nail matrix area only. In four cases, dermal invasion involved areas of the nail unit other than the nail matrix. In 14 cases, dermal invasion involved the nail matrix area as well as other areas of the nail unit. Except for one case, the nail matrix area showed thinner dermal invasion compared with dermal invasion in other areas of the nail unit. In conclusion, dermal invasion of subungual melanoma in the nail matrix area tends to occur later than other areas of the nail unit. Longitudinal incisional biopsy is necessary to accurately evaluate melanoma invasion. The findings of this study suggest that conservative surgical treatment for early subungual melanoma may be justified as the nail matrix area, an area of thin dermis and close proximity to the underlying bone, appears to be more resistant to invasion.
Dika, Emi; Patrizi, Annalisa; Fanti, Pier Alessandro; Alessandrini, Aurora; Sorci, Rita; Piraccini, Bianca Maria; Vaccari, Sabina; Misciali, Cosimo; Maibach, Howard I
Basal cell carcinoma (BCC), the most frequent malignant skin tumor observed in Caucasian adults, especially males, occurs mainly in sun-exposed areas of the body. BCC in the periungual tissues, such as proximal nail fold, nail matrix, nail bed and hyponychium, is rarely reported. We report a patient with two synchronous BCC of the periungual tissue localized in the IV and V fingernail, effectively treated with Mohs micrographic surgery.
Al-Ashhab, Mohamed E
Management of severely comminuted, complete articular tibial pilon fractures (Rüedi and Allgöwer type III) remains a challenge, with few treatment options providing good clinical outcomes. Twenty patients with severely comminuted tibial pilon fractures underwent primary ankle arthrodesis with a retrograde calcaneal nail and autogenous fibular bone graft. The fusion rate was 100% and the varus malunion rate was 10%. Fracture union occurred at a mean of 16 weeks (range, 13-18 weeks) postoperatively. Primary ankle arthrodesis is a successful method for treating highly comminuted tibial pilon fractures, having a low complication rate and a high satisfaction score. [Orthopedics. 2017; 40(2):e378-e381.]. Copyright 2016, SLACK Incorporated.
Anup, Khare; Mehra, M M
Retrograde interlocking nail was used as the method of fixation in 35 different cases of combination of complex femoral fractures. We performed this procedure in fractures of femoral shaft associated with fracture neck femur, pathological fractures of proximal third of femur with trochanteric pathology, ipsilateral fracture of femur and tibia in polytrauma cases with multiple other injuries, in highly obese patients with fracture shaft femur. This technique was also used in cases of pregnancy with fracture shaft femur and in unstable pelvic fracture or dislocation hip associated with fracture shaft femur. Operative technique involved with retrograde insertion of un-reamed, non-cannulated custom made nail through entrance portal in intercondylar notch was applied for fixation of the shaft femur fracture. The other associated fracture around hip was stabilized separately using suitable implant according to type of fracture. In cases of ipsilateral fracture of femur and tibia, femur was stabilized by retrograde interlocking nail and tibia was stabilized by antigrade interlocking nail through same incision at the same sitting. The case was followed up for three years; the average union time was 12 to 18 weeks. Out of 35 cases, 31 cases regained full knee movement. Out of the remaining 4 cases, 2 cases could regain up to 90 degrees of movement, these were old fractures and non-cooperative patients. In one case, patellofemoral arthritis was developed because of an operative error where a nail was not put inside the articular surface. Mal-union was observed in an early case of the series and implant failure was nil. Retrograde interlocking nail was used as the method of fixation in complex fracture problems. Multiple fractures of long bones can be stabilized in one stage, preventing multiple operations at different stages in polytraumatized patients. This resulted in early recovery, lesser hospital stay, and early rehabilitation of patient with good results and is
Our knowledge on stem cells of the hair follicle has increased exponentially after the bulge was characterized as the stem cell niche two decades ago. In contrast, little is known about stem cells in the nail unit. Whereas hair follicles are plentiful and easy to access, the human body has only twenty nails and they are rarely biopsied. Therefore, examining fetal material offers unique advantages. In the following mini-review, our current knowledge on nail stem cells is summarized and analogies to the hair follicle stem cells are drawn.
... may indicate: Dehydration Shock Peripheral vascular disease (PVD) Hypothermia Alternative Names Nail blanch test; Capillary refill time ... Elsevier Saunders; 2016:chap 79. Read More Dehydration Hypothermia Peripheral artery disease - legs Shock Review Date 4/ ...
Mucosal culture; Culture - skin; Culture - mucosal; Nail culture; Culture - fingernail; Fingernail culture ... There, it is placed in a special dish (culture). It is then watched to see if bacteria, ...
Märdian, S; Schwabe, P; Schaser, K-D
The tibia shaft is the most often fractured long bone of human beings. Among others traffic accidents (37.5 %), falls (17.8 %), sport accidents (30.9 %) and assaults (4.5 %) are typical mechanisms. A brief clinical examination including the correct classification of the fracture pattern and even more important the degree of the soft tissue damage are the most crucial factors for the following therapeutic cascade. This follows a defined algorithm based on the degree of soft tissue damage. As biplanar X-ray diagnostics are obligatory, CT scans are subject to complex fracture patterns and accompanying intraarticular pathologies.The treatment of tibial shaft fractures is the preserve of operative stabilization, which should be done primarily depending on the degree of the soft tissue injury. Here intramedullary methods - especially intramedullary nailing - are the golden standard.The most serious complication of these fractures is the development of a compartment syndrome. This requires rapid diagnosis and an adequate surgical management in order to avoid extensive muscle necrosis with ischaemic contractures and irreversible neurovascular deficits. Apart from postoperative infections, which are the predominant complication especially in open injuries, non union provide typical and late complications which are partly difficult to treat. These should, depending on their type, follow a dedicated treatment algorithm.
Mochizuki, Takashi; Kawasaki, Masako; Tanabe, Hiroshi; Ishizaki, Hiroshi
We describe a nail drilling method suitable for the diagnosis of onychomycosis. Thirty-three patients with onychomycosis in which the big toenail had a white band or spike were enrolled in this study. We drilled a hole about 3-mm-wide in the most proximal part of the white band or spike using a ball-shaped metal file and then, through the hole, sampled the underlying nail material softened by fungi after removing the superficial hard nail plate. Fungi in 32 (97.0%) of the nail samples were detected by direct KOH examination. When incubated on Sabouraud's dextrose agar slant with chloramphenicol and cycloheximide, fungal cultures were obtained from 27 (81.8%) of the 33 nail samples. Fourteen of the fungal isolates were identified as T. rubrum, 11 as T. mentagrophytes, and 2 as Acremonium sp. The nail drilling method is suitable for diagnosing onychomycosis with a white band or spike, because it gives a high isolation rate and leaves the patients' nail relatively more intact compared with other methods.
Belinchón Romero, I; Ramos Rincón, J M; Reyes Rabell, F
Leprosy, a disease caused by Mycobacterium leprae, primarily affects the skin and nerves, but the nails are also involved in as many as 3 out of 4 patients .The factors that trigger nail changes in leprosy are numerous and include repeated trauma, neuropathy, vascular impairment, infections, lepra reactions, and the drugs used to manage the disease. The changes most often reported include subungual hematomas, onycholysis, onychauxis, onychogryphosis, pterygium unguis, and onychoheterotopia, most of which can be attributed to nerve damage and trauma. Furthermore, the acro-osteolysis that occurs in the advanced stages of the disease may present with brachyonychia, racquet nails, or even anonychia. Infections of the nail bed leading to paronychia and onychomycosis should also be taken into account in leprosy. Other typical changes include longitudinal striae, pitting, macrolunula, Terry nails, leukonychia, hapalonychia, and Beau lines. In this review, we describe the principal nail changes associated with leprosy. These changes, which are highly varied and diverse in origin, are in fact a reflection of the significant morbidity caused by M. leprae infection. Copyright © 2011 Elsevier España, S.L. and AEDV. All rights reserved.
Omerovic, Djemil; Lazovic, Faruk; Hadzimehmedagic, Amel
The basic principle of non-surgical fracture treatment is to restore the original anatomical position of fractured fragments by different techniques, without direct access to the bone and without further traumatizing of tissues. Intramedullary nailing is synthesis and consolidation of fracture fragments with the main goal to gain strength and permanent placement of the implants. Two techniques of intramedullary osteosynthesis are used: with dynamic or with static intramedullary nail. Dynamization include conversion of static nail by removing screws from the longest fragment. The aim of this study is to determine whether there is a difference in the speed and quality of healing of the type A and B fractures of the femur and tibia treated by static or dynamic intramedullary nails and to compare the results. The study was conducted at the Clinic for Orthopaedics and Traumatology, Clinical Center University Sarajevo from January 2004 to June 2009. The study was retrospective-prospective, manipulative, controlled and it was conducted on a total of 129 patients with closed fractures of the diaphysis of the femur and tibia type A and type B, with different segments of bone, regardless of sex and age structure, with the exception of children under 14 years of age. Precisely there were 47 patients with femoral fractures and 82 patients with tibial fractures. The average number of weeks of healing femoral and tibial fractures was slightly in advantage of static intramedullary osteosynthesis, it was 17.08 weeks (SD=3.382). The average number of weeks of healing in 23 patients with fractures of the femur, treated by dynamic intramedullary osteosynthesis was 17.83 (SD=2.978). We can conclude that static intramedullary nailing osteosynthesis unable movements between fragments which directly stimulates bone formation and formation of minimal callus. Static intramedullary osteosynthesis resolve the problem of stabilizing the fracture, limb shortening and rotation of fragments.
Stephen, Sasha; Tosti, Antonella; Rubin, Adam I
"Nail clipping is a simple technique for diagnosis of several nail unit dermatoses. This article summarizes the practical approach, utility, and histologic findings of a nail clipping in evaluation of onychomycosis, nail unit psoriasis, onychomatricoma, subungual hematoma, melanonychia, and nail cosmetics, and the forensic applications of this easily obtained specimen. It reviews important considerations in optimizing specimen collection, processing methods, and efficacy of special stains in several clinical contexts. Readers will develop a greater understanding and ease of application of this indispensable procedure in assessing nail unit dermatoses."
Shemer, Avner; Davidovici, Batya; Grunwald, Marcelo H; Trau, Henri; Amichai, Boaz
Onychomycosis is a common problem. Obtaining accurate laboratory test results before treatment is important in clinical practice. The purpose of this study was to compare results of curettage and drilling techniques of nail sampling in the diagnosis of onychomycosis, and to establish the best technique and location of sampling. We evaluated 60 patients suffering from distal and lateral subungual onychomycosis and lateral subungual onychomycosis using curettage and vertical and horizontal drilling sampling techniques from three different sites of the infected nail. KOH examination and fungal culture were used for detection and identification of fungal infection. At each sample site, the horizontal drilling technique has a better culture sensitivity than curettage. Trichophyton rubrum was by far the most common pathogen detected by both techniques from all sampling sites. The drilling technique was found to be statistically better than curettage at each site of sampling, furthermore vertical drilling from the proximal part of the affected nail was found to be the best procedure for nail sampling. With each technique we found that the culture sensitivity improved as the location of the sample was more proximal. More types of pathogens were detected in samples taken by both methods from proximal parts of the affected nails.
Shah, Sourabh; Agarwal, Naresh; Jain, Anuj; Srivastav, Shekhar; Thomas, Simon; Agarwal, Shekhar
This MRI based study evaluates morphological differences of proximal tibia (total cross-sectional area, mediolateral and anteroposterior distance) 8-10 mm distal to the lateral tibial plateau. We evaluated the difference in the coverage of the tibial surface between symmetric and asymmetric tibial trays and difference in coverage between males and females. 150 patients who underwent MRI scans for sports related soft tissue injury without osteoarthritis were studied. The tibial trays of the 5 total knee arthroplasty designs (4 symmetric and 1 asymmetric) were scanned. Mean total tibial coverage of all designs was more than 80%. Asymmetric baseplate had maximum total tibial coverage and maximum rate of optimal fit, with only 2% absolute overhang posterolaterally. Females had better tibial coverage as compared to males.
Sobolewski, Piotr; Walecka, Irena; Dopytalska, Klaudia
Nail psoriasis is considered a significant psychological and social problem causing functional impairment in affected patients. Nail changes hamper their daily and occupational activities and contribute to a worse quality of life. Almost 50% of patients with psoriasis vulgaris and up to 80% of patients with psoriatic arthritis are afflicted with nail lesions. The important correlation between psoriatic arthritis and nail changes is well established - the presence of the latter is a strong predictor of the development of arthritis. There is a broad spectrum of nail dystrophies associated with psoriasis, ranging from the common pitting, subungual hyperkeratosis and loosening of the nail plate to less frequent discolouration and splinter haemorrhages. Some of these symptoms are also observed in other nail diseases, and further diagnostics should be performed. The assessment tools NAPSI (Nail Psoriasis Severity Index), mNAPSI (Modified Nail Psoriasis Severity Index), and PNSS (Psoriasis Nail Severity Score) are most commonly used to grade the severity of nail involvement in psoriasis and enable the evaluation of therapy effectiveness. The treatment of nail psoriasis is a major clinical challenge. It should be adjusted to the extent of dermal, articular and ungual lesions. Systemic therapies of psoriasis, especially biological agents, are most likely to be effective in treating nail psoriasis. However, as their use is limited in scope and safety, topical therapy remains a mainstay, and the combination of corticosteroids and vitamin D3 analogues is considered to be most helpful.
Lowe, Brian; Albers, James; Hudock, Stephen; Krieg, Edward
Pneumatic nail guns used in wood framing are equipped with one of two triggering mechanisms. Sequential actuation triggers have been shown to be a safer alternative to contact actuation triggers because they reduce traumatic injury risk. However, the sequential actuation trigger must be depressed for each individual nail fired as opposed to the contact actuation trigger, which allows the trigger to be held depressed as nails are fired repeatedly by bumping the safety tip against the workpiece. As such, concerns have been raised about risks for cumulative trauma injury, and reduced productivity, due to repetitive finger motion with the sequential actuation trigger. This study developed a method to predict cumulative finger flexor tendon travel associated with the sequential actuation trigger nail gun from finger joint kinematics measured in the trigger actuation and productivity standards for wood-frame construction tasks. Finger motions were measured from six users wearing an instrumented electrogoniometer glove in a simulation of two common framing tasks-wall building and flat nailing of material. Flexor tendon travel was calculated from the ensemble average kinematics for an individual nail fired. Finger flexor tendon travel was attributable mostly to proximal interphalangeal and distal interphalangeal joint motion. Tendon travel per nail fired appeared to be slightly greater for a wall-building task than a flat nailing task. The present study data, in combination with construction industry productivity standards, suggest that a high-production workday would be associated with less than 60 m/day cumulative tendon travel per worker (based on 1700 trigger presses/day). These results suggest that exposure to finger tendon travel from sequential actuation trigger nail gun use may be below levels that have been previously associated with high musculoskeletal disorder risk.
Lowe, Brian; Albers, James; Hudock, Stephen; Krieg, Edward
TECHNICAL ABSTRACT Background Pneumatic nail guns used in wood framing are equipped with one of two triggering mechanisms. Sequential actuation triggers have been shown to be a safer alternative to contact actuation triggers because they reduce traumatic injury risk. However, the sequential actuation trigger must be depressed for each individual nail fired as opposed to the contact actuation trigger, which allows the trigger to be held depressed as nails are fired repeatedly by bumping the safety tip against the workpiece. As such, concerns have been raised about risks for cumulative trauma injury, and reduced productivity, due to repetitive finger motion with the sequential actuation trigger. Purpose This study developed a method to predict cumulative finger flexor tendon travel associated with the sequential actuation trigger nail gun from finger joint kinematics measured in the trigger actuation and productivity standards for wood-frame construction tasks. Methods Finger motions were measured from six users wearing an instrumented electrogoniometer glove in a simulation of two common framing tasks–wall building and flat nailing of material. Flexor tendon travel was calculated from the ensemble average kinematics for an individual nail fired. Results Finger flexor tendon travel was attributable mostly to proximal interphalangeal and distal interphalangeal joint motion. Tendon travel per nail fired appeared to be slightly greater for a wall-building task than a flat nailing task. The present study data, in combination with construction industry productivity standards, suggest that a high-production workday would be associated with less than 60 m/day cumulative tendon travel per worker (based on 1700 trigger presses/day). Conclusion and Applications These results suggest that exposure to finger tendon travel from sequential actuation trigger nail gun use may be below levels that have been previously associated with high musculoskeletal disorder risk. PMID
Arteau, Annie; Lewis, Valerae O.; Moon, Bryan S.; Satcher, Robert L.; Bird, Justin E.; Lin, Patrick P.
Background: In growing children, an expandable endoprosthesis is commonly used after distal femoral resection to compensate for loss of the distal femoral physis. Our hypothesis was that such prostheses can affect proximal tibial growth, which would contribute to an overall leg-length discrepancy and cause angular deformity. Methods: Twenty-three skeletally immature patients underwent the placement of a distal femoral expandable endoprosthesis between 1994 and 2012. Tibial length, femoral length, and mechanical axis were measured radiographically to determine the growth rate. Results: No patient had radiographic evidence of injury to the proximal tibial physis at the time of surgery other than insertion of the tibial stem. Fifteen (65%) of the patients experienced less proximal tibial growth in the operative compared with the contralateral limb. In ten (43%) of the patients, the discrepancy progressively worsened, whereas in five (22%) of the patients, the discrepancy stabilized. Seven patients did not develop tibial length discrepancy, and one patient had overgrowth of the tibia. For the ten patients with progressive shortening, the proximal tibial physis grew an average of 4.0 mm less per year in the operative limb. Five (22%) of the patients had ≥20 mm of tibial length discrepancy at last follow-up. Three of these patients underwent contralateral tibial epiphysiodesis. Three patients required corrective surgery for angular deformity. Conclusions: The tibial growth plate may not resume normal growth after implantation of a distal femoral prosthesis. Physeal bar resection, prosthesis revision, and contralateral tibial epiphysiodesis may be needed to address tibial growth abnormalities. Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence. PMID:26582624
Raja Sabapathy, S; Venkatramani, H; Bharathi, R; Jayachandran, S
Fifteen finger tip amputations through the proximal half of the nail bed were reconstructed with palmar V-Y advancement flaps and full thickness nail bed grafts. The undersurface of the V-Y flap was sutured to the nail bed remnant and the raw area was covered with full thickness nail bed grafts from the amputated part. They were followed for a minimum period of one year and the nail bed grafts took fully in all patients. The results were best in the thumb and least favourable in the little finger but all the patients were happy with the cosmetic result and the functional outcome. This technique results in an average gain of 5 mm of extra length to the nail. This is a useful technique when replantation of a distal fingertip amputation is not possible. Copyright 2002 The British Society for Surgery of the Hand.
Fernandez-Flores, Angel; Saeb-Lima, Marcela; Martínez-Nova, Alfonso
In this report, we review several inflammatory infectious and tumoral conditions of the nail unit. We emphasize the anatomic peculiarities of such pathologies of the nail unit and provide some required diagnostic criteria.
Engineer, L; Norton, L A; Ahmed, A R
Nail involvement in pemphigus vulgaris is relatively rare. We describe a case of severe pemphigus involving both the skin and oral mucosa in which an acute exacerbation was preceded by the onset of nail involvement of all 4 extremities. Nail involvement occurred in the form of hemorrhagic paronychia of multiple digits. Oral, cutaneous, and nail manifestations of the disease were all well controlled by systemic therapy. A review of the literature on nail involvement in pemphigus reveals that this involvement may be manifested in multiple ways, with chronic paronychia and onychomadesis being the most common. Involvement of the nail occurs most frequently either as part of the initial presentation, or just before or concurrent with a flare of pre-existing disease. Nail involvement, when it occurs, is usually present when the disease is severe. Topical therapy is insufficient, and systemic therapy is warranted. In the majority of cases, nail recovery is complete, with no residual damage.
Inamadar, Arun C; Palit, Aparna
Nails are cutaneous appendages mostly involved in mechanical functions. However, nails may reflect presence of various systemic disorders evidenced by alteration of their shape, size, color or texture. Genodermatoses are multisystem disorders with cutaneous involvement. Many of the genodermatoses present with nail changes and some of these may be the clinical pointers to the diagnosis. Diagnostic clues to various genodermatoses derived from nail findings have been discussed.
Moon, Sang Won; Park, Sin Hyung; Lee, Byung Hoon; Oh, Minkyung; Chang, Minho; Ahn, Jin Hwan; Wang, Joon Ho
To evaluate whether hinge position affects the change in posterior tibial slope in medial open-wedge high tibial osteotomy (HTO). We retrospectively evaluated 19 knees from 17 patients who underwent medial open-wedge HTO by 3-dimensional computed tomography scan before and after surgery. A 3-dimensional image model was constructed by applying reverse-engineering software to the computed tomography DICOM (Digital Imaging and Communications in Medicine) files. The hinge axis (i.e., the position of the hinge compared with the anteroposterior axis on an axial view), posterior tibial slope, medial-proximal tibial angle, and gap ratio (i.e., the ratio of anterior gap to posterior gap in the opened wedge) were measured. The mean hinge axis was 4.92° ± 3.86°. Posterior tibial slope increased from 7.29° ± 2.56° preoperatively to 10.48° ± 3.01° postoperatively (P = .001). The mean medial-proximal tibial angle was 85.96° ± 1.97° preoperatively and 93.13° ± 3.17° postoperatively (P = .001). The mean gap ratio was 62.48% ± 7.26%. Linear regression analysis determined that the hinge axis (P = .0001) was a significant factor changing posterior tibial slope. Hinge position affected the change in posterior tibial slope in medial open-wedge HTO; in particular, a posterolateral hinge position led to an increase in posterior tibial slope. Level IV, therapeutic study. Copyright © 2015 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.
Tiwari, Vivek; Sampath Kumar, Venkatesan; Poudel, Rishi R; Kumar, Ashok; Khan, Shah Alam
Osteochondromas are the most common bone tumours. Although these tumors are relatively common in the long bones of children, the varied clinical and radiographic presentation of such neoplasms around the knee joint can cause diagnostic delays, especially when not associated with a palpable swelling. Proximal tibial osteochondromas can sometimes unusually present as spurs/ rose thorns leading to pes anserinus bursitis and vague knee pain. We describe the clinico-radiographic features of such proximal tibial metaphyseal osteochondromas giving rise to pes anserinus bursitis in three children, including bilaterally symmetrical osteochondroma in one of the cases, who were treated conservatively with good outcomes.
Wiebking, Ulrich; Liodakis, Emmanouil; Kenawey, Mohamed; Krettek, Christian
Background Three types of telescopic nails are mainly used for intramedullary limb lengthening nowadays. Despite some important advantages of this new technology (e.g. controlled distraction rate, not restricted availability, possibility to perform accordion maneuvers), few articles exist on clinical results and complications after lengthening with the PRECICETM nail (Ellipse, USA). Objectives The aim of the current study was to describe and analyze the complications associated with lengthening with the PRECICETM nail. Are the problems preventable when using the PRECICE, related to the distraction rate control, the lengthening goals and technique and handling? Methods We retrospectively reviewed the charts of 9 patients operated between 2012 and 2013 with a PRECICETM nail for a leg length discrepancy (LLD). The mean age of the patients was 32 years (range, 17 - 48 years). There were 5 femoral and 4 tibial procedures. The causes of LLD were posttraumatic (n = 5) and congenital (n = 4). The mean LLD was 36.4 ± 11.4 mm. The minimum follow-ups were 2 months (average, 5 months; range, 2 - 9 months). Results The mean distraction rate was 0.5 ± 0.1 mm/day. We observed in 7 patients differences in achieving the lengthening goals (average, 1.6 mm; range, -20.0 - 5.0 mm). Average lengthening was 34.7 ± 10.7 mm. All patients reached normal alignment and normal joint orientation. An unintentional loss of the achieved length during the consolidation phase was noticed in patients with delayed bone healing in two cases. In the first case (loss of 20mm distraction) the nail could be redistracted and the goal length was achieved. In the second case (loss of 10mm distraction) the nail broke shortly after the diagnosis and the nail was exchanged. Conclusions We report of loss of achieved length after lengthening with a telescopic nail. Weight bearing before complete consolidation of the regenerate might be a risk factor for that. Thorough examination of the limb length and careful
Shah, M H; Heffernan, G; McGuinness, A J
The Titanium Elastic Nail (TEN) offers a number of potential advantages over traditional ways of treating long bone fractures particularly in the paediatric population. These advantages include earlier mobilisation and shorter hospital stay and less risk of loss of fracture position. These advantages are most apparent and significant when treating femoral fractures in children where the length of hospital stay is reduced from several weeks to a typical period of 5 to 8 days. We have reviewed our early experience of using these implants over the past 2 years. Patients were assessed clinically and radiologically. 13 patients were treated using the TEN during this period. There were 2 femoral fractures, 4 humeral fractures, 1 tibial and 6 forearm fractures treated using the Titanium Elastic Nail. All fractures united during the study period. However 1 humeral fracture required a secondary bone grafting and plating for delayed union and 1 fracture lost position during follow-up. Insertion point pain was a problem in 4 patients but this resolved after nail removal in all. There was 1 superficial wound infection which resolved with antibiotics and 1 superficial wound infection of an open fracture wound which resolved following nail removal and antibiotics. There were no cases of deep infection. There were no limb length discrepancy or rotational or angular malalignment problems. Biomechanical principles and technical aspects of this type of fixation are discussed.
Riedel, Matthew D; Gonzalez, Tyler; Kwon, John Y
This study was to determine the angle of bend that can be placed in a ball-tip guide wire while still allowing passage of reamers and nails of several commonly utilized nailing systems. Ball-tip guide wires, opening reamer tips, femoral nails, and tibial nails were collected from several manufacturers. Guide wires were incrementally bent 3 cm from the tip and passed through the reamer tip, tibial nail, and femoral nail until unable to pass. All systems tested demonstrated that the reamer, with its relative smaller diameter cannula as compared to the nails themselves, determined the smallest tolerable bend to be able to pass the bent guide wire. The bend angle tolerated by reamer tips was on average 7° (4-9°). The bend angle tolerated by femoral nails was more consistent between the tested systems and was on average 15.5° (12-18°). The bend angle tolerated by tibial nails had the most variability between manufacturers and was on average 16° (13-21°). Knowing the degree of guide wire bend which is tolerated can save time in equipment preparation as well as allow one to pre-bend the guide wire and know the intramedullary nail and/or reamers will likely pass. We hope the information provided in this work increases awareness of the potential technical issues with guide wire over-bending and that surgeons may err on the side of minimizing the bend in order to save time in the OR, decrease frustration and eliminate intraoperative complications that can occur. Copyright © 2015 Elsevier Ltd. All rights reserved.
Objective The purpose of this study is to compare the clinical effects of our self-designed rotary self-locking intramedullary nail (RSIN) and interlocking intramedullary nail (IIN) for long bone fractures. Methods A retrospective study was performed in 1,704 patients who suffered bone fractures and underwent RSIN or IIN operation in our hospital between March 1999 and March 2013, including 494 with femoral fractures, 572 with humeral fractures, and 638 with tibial fractures. Among them, 634 patients were followed up for more than 1 year. The operative time, intraoperative blood loss, postoperative complications, healing rate, and the excellent and good rate of functional recovery were compared between two groups. Results Compared with IIN group, RSIN group exhibited significantly shorter operative time and less intraoperative blood loss no matter for humeral, femoral, or tibial fractures (all p < 0.001). The healing rate in patients with more than 1 year follow-up was significantly higher in RSIN group for femoral and tibial fractures (both p < 0.05). In RSIN group, no nail breakage or loosening occurred, but radial nerve injury and incision infection were respectively observed in one patient with humeral fracture. In IIN group, nail breakage or loosening occurred in 7 patients with femoral fractures and 16 patients with tibial fractures, radial nerve injury was observed in 8 patients with humeral fractures, and incision infection was present in 2 patients with humeral fractures and 1 patient with femoral fracture. The complication rate of IIN group was significantly higher than that of RSIN group (p < 0.05). However, there were no significant differences in the excellent and good rate of shoulder, elbow, knee, and ankle joint functional recovery between RSIN group and IIN group. Conclusion RSIN may be a reliable and practical alternative method for the treatment of long bone fractures. PMID:25047454
Liu, Bailian; Xiong, Ying; Deng, Hong; Gu, Shao; Jia, Fu; Li, Qunhui; Wang, Daxing; Gan, Xuewen; Liu, Wei
The purpose of this study is to compare the clinical effects of our self-designed rotary self-locking intramedullary nail (RSIN) and interlocking intramedullary nail (IIN) for long bone fractures. A retrospective study was performed in 1,704 patients who suffered bone fractures and underwent RSIN or IIN operation in our hospital between March 1999 and March 2013, including 494 with femoral fractures, 572 with humeral fractures, and 638 with tibial fractures. Among them, 634 patients were followed up for more than 1 year. The operative time, intraoperative blood loss, postoperative complications, healing rate, and the excellent and good rate of functional recovery were compared between two groups. Compared with IIN group, RSIN group exhibited significantly shorter operative time and less intraoperative blood loss no matter for humeral, femoral, or tibial fractures (all p < 0.001). The healing rate in patients with more than 1 year follow-up was significantly higher in RSIN group for femoral and tibial fractures (both p < 0.05). In RSIN group, no nail breakage or loosening occurred, but radial nerve injury and incision infection were respectively observed in one patient with humeral fracture. In IIN group, nail breakage or loosening occurred in 7 patients with femoral fractures and 16 patients with tibial fractures, radial nerve injury was observed in 8 patients with humeral fractures, and incision infection was present in 2 patients with humeral fractures and 1 patient with femoral fracture. The complication rate of IIN group was significantly higher than that of RSIN group (p < 0.05). However, there were no significant differences in the excellent and good rate of shoulder, elbow, knee, and ankle joint functional recovery between RSIN group and IIN group. RSIN may be a reliable and practical alternative method for the treatment of long bone fractures.
Ruffilli, A; Traina, F; Pilla, F; Fenga, D; Faldini, C
Shoulder impairment following anterograde intramedullary nailing for humeral shaft fractures represents a challenging problem for the orthopedic surgeon. Traditional retrograde nailing lowers the rates of shoulder impairment although exposing the surgeons to severe technical issues related to the proximal interlocking. The Marchetti Vicenzi nail (MVN) permits a retrograde insertion along with a self-locking mechanism that lowers the risk of iatrogenic damage during proximal interlocking. Aim of this literature review was to evaluate all the case series dealing with MVN and the obtained results in terms of union rates, complications, and functional outcomes in order to evaluate evidence that would substantiate the adoption of MVN in the treatment of humeral shaft fractures. A search was performed using the keywords "humeral shaft fracture nail," "humeral retrograde nail," "humeral elastic nail," "Marchetti Vicenzi nail," "Marchetti nail," "Vicenzi nail." After accurate revision 13 articles found to be relevant with a total of 532 humeral fractures (traumatic and pathologic) and non-unions treated with MVN. The cumulative healing rate reported is 93.7 % with 6.3 % of non-unions. Despite the fact that obtained results compare favorably to the published data on the outcome of anterograde nailing, the evaluated studies presented a huge number of methodological flaws, thus making it difficult to recommend the adoption of MVN in preference of other better-validated forms of treatment.
Holstein, J H; Menger, M D; Culemann, U; Meier, C; Pohlemann, T
We herein report on a novel locking intramedullary nail system in a murine closed femur fracture model. The nail system consists of a modified 24-gauge injection needle and a 0.1-mm-diameter tungsten guide wire. Rotation stability was accomplished by flattening the proximal and distal end of the needle. Torsional mechanical testing of the implants in osteotomized cadaveric femora revealed a superiority of the locking nail (3.9+/-1.0 degrees rotation at a torque of 0.9 Nmm, n=10) compared to the unmodified injection needle (conventional nail; 52.4+/-3.2 degrees, n=10, p<0.05). None of the implants, however, achieved the rotation stability of unfractured femora (0.3+/-0.5 degrees, n=10). In a second step, we tested the feasibility of the in vivo application of the locking nail to stabilize a closed femoral midshaft fracture in C57BL/6 mice. Of interest, none of the 10 animals showed a dislocation of the locking nail over a 5-week period, while 3 of 4 animals with conventional nail fracture stabilization showed a significant pin dislocation within the first 3 days (p<0.05). Mechanical testing after 5-weeks stabilization with the locking nail revealed an appropriate bone healing with a torque at failure of 71.6+/-3.4% and a peak rotation before failure of 68.4+/-5.3% relative to the unfractured contralateral femur. With the advantage that closed fractures can be fixed with rotation stability, the herein introduced model may represent an ideal tool to study bone healing in transgenic and knockout mice.
Cai, Gang; Yang, Lang; Saleh, Michael; Coulton, Les
Limb lengthening by tibial callotasis is usually performed in the metaphysis but may cause growth inhibition. Is diaphyseal lengthening more advantageous? Sixteen immature rabbits underwent 30% diaphyseal lengthening by tibial callotasis. The tibial length was measured on radiographs at the end of the distraction period and after an additional 5 weeks. The proximal and distal growth plates were assessed histomorphometrically. Osteotomy stimulated tibial elongation; however, combined with diaphyseal lengthening the stimulation was suppressed resulting in longitudinal growth that matched the control side. In longer lengthenings of limbs diaphyseal callotasis may be more advantageous than metaphyseal by not inhibiting longitudinal growth.
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Walmsley, David; Nicayenzi, Bruce; Kuzyk, Paul Rt; Machin, Alan; Bougherara, Habiba; Schemitsch, Emil H; Zdero, Radovan
Unstable intertrochanteric fractures are commonly treated with a cephalomedullary nail due to high failure rates with a sliding hip screw. The Omega3 Trochanteric Stabilizing Plate is a relatively new device that functions like a modified sliding hip screw with a proximal extension; however, its mechanical properties have not been evaluated. This study biomechanically compared a cephalomedullary nail, that is, Gamma3 Nail against the Omega3 plate. Unstable intertrochanteric fractures were created in 24 artificial femurs. Experimental groups were as follows: Nail (i.e. Gamma3 Nail) (n = 8), Plate A (i.e. Omega3 plate with four distal non-locking screws and no proximal locking screws) (n = 8), Plate B (i.e. Plate A plus five proximal locking screws) (n = 8), Plate C (i.e. Omega3 plate with three distal locking screws and no proximal locking screws) (n = 8), and Plate D (i.e. Plate C plus five proximal locking screws) (n = 8). All specimens were stiffness tested, while the Nail and Plate D groups were also strength tested. For lateral bending, Plate B was less stiff than the Nail (p = 0.001) and Plate A (p = 0.009). For torsion, Plate A was less stiff than Plate D (p = 0.020). For axial compression, the Nail was less stiff than Plate A (p = 0.036) and Plate B (p = 0.008). Axial strength for the Nail (5014 ± 308 N) was 66% higher than the Plate D construct (2940 ± 411 N) (p < 0.001). All Nails failed by partial or complete cutout through the femoral head and neck, but Plate D failed by varus collapse and deformation of the lag screw. When the cephalomedullary nail is clinically contra-indicated, this study supports the use of the Omega3 plate, since it had similar stiffness in three test modes to the Gamma3 Nail, but had lower strength. Stability of Omega3 plate constructs was not improved with locked fixation proximally or distally.
Szyber, P; Skóra, J; Rybak, W; Pupka, A
Due to its anatomical location the popliteal artery is exposed to injury during surgical procedures in the region of the knee joint, in particular during high-level corrective osteotomies of the proximal tibial epiphysis. Nevertheless, posttraumatic (iatrogenic) pseudoaneurysm constitutes a very rare complication of the procedure. Only few reports of such complication have been published and they were usually connected with lateral tibial osteotomy - the accidents after medial osteotomy are seldom. The complication we report was observed in a 52-year-old female patient after corrective osteotomy of the medial portion of the proximal tibial epiphysis. The complication was diagnosed 7 days after surgery on US-examination and subsequently confirmed by emergently performed angio-CT. The patient was referred for urgent reconstructive surgery. No significant complications were observed, neither postoperatively nor during follow-up visits.
Banga, Gurvinder; Patel, Kalpana
Background: With the increasing use of nail paints, nail art, acetone, repeated manicures, cosmetic nail procedures and detergents, the nail plate undergoes regular damage resulting in rough, lusterless and pigmented nails. Besides that onychomycosis, nail lichen planus, nail pitting and ridging due to various diseases also cause cosmetically disfiguring nails. Objective: The study is directed toward use of 70% glycolic acid for controlled keratolysis of the nail-plate, resulting that could result in shinier, smoother and brighter nails. Materials and Methods: A prospective single-center open-label uncontrolled study of 31 patients, 22 with dry, rough, discolored nails and 9 with hyperkeratotic nails were included in the study group. After examination and ruling out any infection, petroleum jelly was applied on the cuticle margins of the nails for protection and 70% glycolic acid was applied over the nail plate for 45 minutes. In dry rough discolored nails, only a single sitting was done while in hyper-keratotic nail conditions multiple weekly sittings were done. Results: In 22 patients with dry rough nails, 80% showed good improvement, 10% showed average improvement, whereas 10% were non-responsive. Nine patients with thickened nail plate showed good improvement in 60% average improvement in 25% improvement and 15% were non-responsive, after multiple sessions. Conclusion: Controlled keratolysis of the nail plate with application of 70% glycolic acid can be a promising treatment for modality for thick, uneven, rough and pigmented nail-plate conditions with cosmetically pleasing results. PMID:25722596
De Salazar, Alvaro Ortiz; Muñoz, Fernando; Antoñana, Mirel; Aramendi, José I.; Castellanos, Enrique; Loizate, Alberto; Calderon, Antonio; Llorente, Alberto; Serrano, Alberto
We present a clinical case of chronic dissection of the anterior tibial artery leading to acute aneurysmal dilatation. Our patient, a 22-year-old man, had a history of trauma at the middle third of his left leg. Because of impending ischemia, he was diagnosed by emergency arteriography. We ligated the proximal and distal ends of the dissection and used a reversed saphenous vein for a short end-to-end bypass. Although the evolution of this dilatation had been silent, its clinical presentation was spectacular. The case is worthy of attention because of its extreme rarity, both as a dissection of a peripheral artery caused by trauma and as an aneurysmal dilatation at tibial level. (Texas Heart Institute Journal 1991;18:223-5) Images PMID:15227485
The operative treatment of tibial fractures in late pregnancy is a controversial issue that is rarely discussed in the literature. Here we present a case of a tibial diaphyseal fracture in a woman that was 36 weeks pregnant, which was treated with intramedullary nails under noninvasive foetal monitoring with cardiotocography. The patient underwent a successful surgery, and no harm or adverse events to either the mother or the foetus were reported during or after the procedure. Following surgery, the mother had a comfortable pregnancy and a normal spontaneous vaginal delivery with a healthy newborn. PMID:28070433
Segal, Kira; Ilizarov, Svetlana; Fragomen, Austin T.; Ilizarov, Gabriel
Background Optimal leg alignment is the goal of tibial osteotomy. The Taylor Spatial Frame (TSF) and the Ilizarov method enable gradual realignment of angulation and translation in the coronal, sagittal, and axial planes, therefore, the term six-axis correction. Questions/purposes We asked whether this approach would allow precise correction of tibial deformities. Methods We retrospectively reviewed 102 patients (122 tibiae) with tibial deformities treated with percutaneous osteotomy and gradual correction with the TSF. The proximal osteotomy group was subdivided into two subgroups to distinguish those with an intentional overcorrection of the mechanical axis deviation (MAD). The minimum followup after frame removal was 10 months (average, 48 months; range, 10–98 months). Results In the proximal osteotomy group, patients with varus and valgus deformities for whom the goal of alignment was neutral or overcorrection experienced accurate correction of MAD. In the proximal tibia, the medial proximal tibial angle improved from 80° to 89° in patients with a varus deformity and from 96° to 85° in patients with a valgus deformity. In the middle osteotomy group, all patients had less than 5° coronal plane deformity and 15 of 17 patients had less that 5° sagittal plane deformity. In the distal osteotomy group, the lateral distal tibial angle improved from 77° to 86° in patients with a valgus deformity and from 101° to 90° for patients with a varus deformity. Conclusions Gradual correction of all tibial deformities with the TSF was accurate and with few complications. Level of Evidence Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence. PMID:19911244
Tibial dyschondroplasia (TD) is a poultry leg problem that affects the proximal growth plate of tibia preventing its transition to bone. To understand the disease-induced proteomic changes we compared the protein extracts of cartilage from normal and TD- affected growth plates. TD was induced by fe...
In brief Stress fractures of the proximal middle third of the tibia are common; those of the distal tibia are less common; and longitudinal stress fractures are rare. The basketball player in this case report had a rare longitudinal tibial pilon stress fracture, for which few diagnostic or treatment guidelines existed.
Ozel, Omer; Yucel, Bulent; Mutlu, Serhat; Orman, Osman; Mutlu, Harun
In this study, postoperative changes in the posterior tibial slope angle and clinical outcomes following open-wedge high tibial osteotomy were evaluated. This study included 39 knees (18 left, 21 right) of 35 patients (three male, 32 female; median age, 53 years; age range 37-64 years) with symptomatic isolated medial joint osteoarthritis who underwent open-wedge high tibial osteotomy and fixation with a Puddu plate. The patients were clinically assessed according to the Lysholm knee score, a visual analogue pain scale, and a patient satisfaction questionnaire. Radiological assessment was made according to the changes in the posterior tibial slope angle and the correlation between these changes and clinical signs. The median follow-up period was 11 years (range 7-14 years). Significant improvements were observed in the preoperative and postoperative clinical scores of the Lysholm knee scale, visual analogue pain scale, and patient satisfaction questionnaire (p < 0.05). Radiological assessment showed that the posterior tibial slope angle was significantly higher during the postoperative and follow-up periods (p 0.05). There was no correlation between the postoperative Lysholm scores and the increase in the posterior tibial slope angle (p = n.s.). We conclude that both the conventional Puddu plate design and its anteromedial plate placement are what increase the tibial slope after an opening-wedge proximal tibial osteotomy. Therefore, current new plate design may help preserve the posterior tibial slope angle. IV.
Zaikovska, Olga; Pilmane, Mara; Kisis, Janis
Patients of onychomycosis are common in the dermatology practice. Contemporary morphology creates opportunities to study the functional units of the nail when such infections occur from morphopathological point of view. There were 22 nails biopsies from onychomycosis patients taken for the research of morphopathological changes in the thickened nail plate affected by onychomycosis. Samples of cadaverous' nails were used as a control material. The material was stained with haematoxylin and eosin and immunohistochemical methods. Terminal deoxynucleotidyl transferase dUTP nick end labelling reaction and periodic acid-Schiff reaction were also performed. We found patchy hypertrophy in the granulose layer of the epidermis, with focal acanthosis. In the horn layer, we identified nests of parakeratosis of various sizes, with incorporations of homogenous and eosinophil masses. We found high levels of interleukin 6 and interleukin 10 positive cells in the nail bed and in the bloodstream. Interleukin 1, however, was not a part of any of the functional units of any of the nails. Significant amount of fibres containing human beta defensin-2 were found in the bed and plate of the nail. Therefore one can conclude that as regards the nails affected by onychomycosis, the most effective morphopathogenical processes include cytokine and defensin excretion occurrence in the nail bed.
Zheng, Xuan-Lin; Park, Young-Chang; Kang, Dong-Hyun; Seok, Sang-Ok; Yoon, Yeo-Kwon; Yang, Kyu-Hyun
We present a simple method to remove the distal portion of the broken nail just using the bulb-tipped guide pin and a blocking Kirschner wire. At first, we removed the proximal part of the broken nail and all interlocking screws. Next, we introduced the bulb-tipped guide wire into the distal part of the nail with fluoroscopic guidance until it passed the interlocking hole that would be used. After snugly fitting the blocking Kirschner wire into the interlocking hole of the nail, the bulb-tipped guide wire is then pulled to engage the blocking wire complex in the interlocking hole. The bulb-tipped guide wire and broken nail are removed by sequential stroke using a ram. Copyright © 2016 Elsevier Ltd. All rights reserved.
Oberlin, Kate E
This article highlights pearls shared during a unique and enlightening lecture by Antonella Tosti, MD, a professor at the University of Miami Health System, Florida, on the presentation and management of common pediatric nail diseases. These clinical pearls are shared to help deliver utmost care to our pediatric patients presenting with nail pathology and may help shed light on the management of pediatric nail diseases.
Palmu, Sauli A; Auro, Sampo; Lohman, Martina; Paukku, Reijo T; Peltonen, Jari I; Nietosvaara, Yrjänä
Background Tibial fracture is the third most common long-bone fracture in children. Traditionally, most tibial fractures in children have been treated non-operatively, but there are no long-term results. Methods 94 children (64 boys) were treated for a tibial fracture in Aurora City Hospital during the period 1980–89 but 20 could not be included in the study. 58 of the remaining 74 patients returned a written questionnaire and 45 attended a follow-up examination at mean 27 (23–32) years after the fracture. Results 89 children had been treated by manipulation under anesthesia and cast-immobilization, 4 by skeletal traction, and 1 with pin fixation. 41 fractures had been re-manipulated. The mean length of hospital stay was 5 (1–26) days. Primary complications were recorded in 5 children. The childrens’ memories of treatment were positive in two-thirds of cases. The mean subjective VAS score (range 0–10) for function appearance was 9. Leg-length discrepancy (5–10 mm) was found clinically in 10 of 45 subjects and rotational deformities exceeding 20° in 4. None of the subjects walked with a limp. None had axial malalignment exceeding 10°. Osteoarthritis of the hip and/or knee was seen in radiographs from 2 subjects. Interpretation The long-term outcome of tibial fractures in children treated non-operatively is generally good. PMID:24786903
Chaudhary, M E; Walker, P S
Tibial component loosening is an important failure mode in unicompartmental knee arthroplasty (UKA) which may be due to the 6-8 mm of bone resection required. To address component loosening and fixation, a new early intervention (EI) design is proposed which reverses the traditional material scheme between femoral and tibial components. The EI design consists of a plastic inlay for the distal femur and a thin metal plate for the proximal tibia. With this reversed materials scheme, the EI design requires minimal tibial bone resection compared with traditional UKA. This study investigated, by means of finite element (FE) simulations, the advantages of a thin metal tibial component compared with traditional UKA tibial components, such as an all-plastic inlay or a metal-backed onlay. We hypothesized that an EI tibial component would produce comparable stress, strain, and strain energy density (SED) characteristics to an intact knee and more favorable values than UKA components, due primarily to the preservation of dense cancellous bone near the surface. Indeed, FE results showed that stresses in the supporting bone for an EI design were close to intact, while stresses, strains, and strain energy densities were reduced compared with an all-plastic UKA component. Analyzed parameters were similar for an EI and a metal-backed onlay, but the EI component had the advantage of minimal resection of the stiffest bone.
Nha, Kyung-Wook; Kim, Hyun-Jung; Ahn, Hyeong-Sik; Lee, Dae-Hee
It is unclear whether open- or closed-wedge high tibial osteotomy (HTO) results in significant changes in posterior tibial slope, with no consensus on the magnitude of such changes. Furthermore, methods of measuring posterior tibial slope differ among studies. This meta-analysis was therefore designed to evaluate whether posterior tibial slope increases after open-wedge HTO and decreases after closed-wedge HTO and to quantify the magnitudes of the slope changes after open- and closed-wedge HTO using various methods of measuring posterior tibial slope. Posterior tibial slope increases after open-wedge and decreases after closed-wedge HTO. The magnitude of change is similar for the 2 methods, and the value obtained for posterior tibial slope change is affected by the method of measurement. Meta-analysis. Multiple comprehensive databases, including MEDLINE, EMBASE, the Cochrane Library, and KoreaMed, were searched for studies that evaluated the posterior slope of the proximal tibia in patients who had undergone open- and/or closed-wedge HTO. Studies were included that compared pre- and postoperative posterior tibial slopes, regardless of measurement method, including anterior and posterior tibial cortex or tibial shaft axis as a reference line, in patients who underwent open- or closed-wedge HTO. The quality of each included study was appraised with the Newcastle-Ottawa Scale. Twenty-seven studies were included in the meta-analysis. Pooled data, which included subgroups of 3 methods, showed that posterior tibial slope increased 2.02° (95% CI, 2.66° to 1.38°; P = .005) after open-wedge HTO and decreased 2.35° (95% CI, 1.38° to 3.32°; P < .001) after closed-wedge HTO. This meta-analysis confirmed that posterior tibial slope increased after open-wedge HTO and decreased after closed-wedge HTO when the results of a variety of measurement methods were pooled. The magnitude of change after open- and closed-wedge HTO was similar and small (approximately 2°), suggesting
Restoration of a stable and plantigrade foot in deformities of the ankle and/or hindfoot and concomitant degenerative changes at the ankle and subtalar joints. Deformities at the ankle and/or hindfoot and concomitant degenerative changes at the ankle and subtalar joint. Failed (corrective) arthrodesis of the ankle and subtalar joints. Fused ankle and degeneration of the subtalar joint. Failed total ankle replacement with insufficient substance of talar body and/or degeneration of subtalar joint. Massive hindfoot instability. Active local infection or relevant vascular insufficiency, possible preservation of the ankle or subtalar joint (relative contraindication). Prone position and posterolateral approach to ankle and subtalar joints (alternative supine position/anterior approach; lateral position/lateral approach). Exposition of ankle and subtalar joints and removal of remaining cartilage. Optional corrective osteotomies and/or bone grafting. Correction and optional fixation of the corrected position with 2.0 mm K-wires. Mechanically navigated insertion of a retrograde guide wire in projection of the tibial axis and insertion of a second guide wire through the entry point of the nail lateral and dorsal to the tibial axis. Reaming and insertion of the A3 nail with a distal double bend; one posterior and one lateral, and a proximal bend corresponding to a slight recurvatum. Insertion of locking screws into the calcaneus, talus and tibia (twice with optional static or dynamic locking). Optional compression between calcaneus and talus, and between tibia and talus. Insertion of a drainage and layer-wise closure. For the first 6 weeks 15 kg partial weight bearing in an orthosis, followed by full weight bearing in a stable standard shoe. In October 2010 (n = 2) and from 15 October 2011 to 13 April 2012 (n = 26) 28 arthrodeses (with/without correction) with A3 fixation were performed. In all cases, exact nail placement was achieved. Thirteen cases completed
Wei, Shijun; Cai, Xianhua; Huang, Jifeng; Xu, Feng; Liu, Ximing; Wang, Qing
Recombinant human bone morphogenetic protein-2 (rhBMP-2) improves healing of open tibial fractures treated with intramedullary nail fixation. However, routine use has not occurred. The purposes of the current study were to provide a systematic review of the literature using rhBMP-2 in the treatment of acute open tibial fractures treated with intramedullary nail fixation and to provide a meta-analysis of the randomized, controlled trials. Multiple databases, reference lists of relative articles, and main orthopedic journals were searched. The basic information and major results were compared. Four studies with a total of 609 patients were included.The secondary intervention rate in the standard-of-care (SOC) group was significantly higher than in the rhBMP-2 combined with absorbable collagen sponge (rhBMP-2/ACS) group (27.1% vs 17.5%, respectively; P<.01). The treatment failure rate in the SOC group was significantly higher (34.3% vs. 21.4%, respectively; P<.01). No significant differences were found in infection rate, hardware failure rate, fracture healing rate at 20 weeks, and postoperative pain level. For patients treated with reamed intramedullary nail fixation, only the treatment failure rate in the SOC group was significantly higher (21.5% vs 14.2%, respectively; P=.02); no other significant difference was observed. Adding rhBMP-2 to the treatment of Gustilo-Anderson grade IIIA and B open tibial fractures led to net savings of approximately $6000 per case.Recombinant human bone morphogenetic protein-2 added to intramedullary nail fixation of open tibial fractures could reduce the frequency of secondary interventions and total health care costs. For reamed patients, adding rhBMP-2 reduced treatment failure. This analysis supports the clinical efficacy of rhBMP-2/ACS for the treatment of these severe fractures. Copyright 2012, SLACK Incorporated.
Background and purpose Bilateral tibial lengthening has become one of the standard treatments for upper segment-lower segment disproportion and to improve quality of life in achondroplasia. We determined the effect of tibial lengthening on the tibial physis and compared tibial growth that occurred at the physis with that in non-operated patients with acondroplasia. Methods We performed a retrospective analysis of serial radiographs until skeletal maturity in 23 achondroplasia patients who underwent bilateral tibial lengthening before skeletal maturity (lengthening group L) and 12 achondroplasia patients of similar height and age who did not undergo tibial lengthening (control group C). The mean amount of lengthening of tibia in group L was 9.2 cm (lengthening percentage: 60%) and the mean age at the time of lengthening was 8.2 years. The mean duration of follow-up was 9.8 years. Results Skeletal maturity (fusion of physis) occurred at 15.2 years in group L and at 16.0 years in group C. The actual length of tibia (without distraction) at skeletal maturity was 238 mm in group L and 277 mm in group C (p = 0.03). The mean growth rates showed a decrease in group L relative to group C from about 2 years after surgery. Physeal closure was most pronounced on the anterolateral proximal tibial physis, with relative preservation of the distal physis. Interpretation Our findings indicate that physeal growth rate can be disturbed after tibial lengthening in achondroplasia, and a close watch should be kept for such an occurrence—especially when lengthening of more than 50% is attempted. PMID:22489887
Tsukeoka, T; Tsuneizumi, Y; Lee, T H
We performed a CT-based computer simulation study to determine how the relationship between any inbuilt posterior slope in the proximal tibial osteotomy and cutting jig rotational orientation errors affect tibial component alignment in total knee replacement. Four different posterior slopes (3°, 5°, 7° and 10°), each with a rotational error of 5°, 10°, 15°, 20°, 25° or 30°, were simulated. Tibial cutting block malalignment of 20° of external rotation can produce varus malalignment of 2.4° and 3.5° with a 7° and a 10° sloped cutting jig, respectively. Care must be taken in orientating the cutting jig in the sagittal plane when making a posterior sloped proximal tibial osteotomy in total knee replacement.
Zamora, Rodolfo; Wright, Craig; Short, Adam; Seligson, David
Intramedullary nailing is one viable option for treating fractures of the tibia with a short, proximal segment. For a procedure being carried out with the knee in a semi-extended position, either a suprapatellar or parapatellar approach may be used. The objective of this study is to demonstrate whether the entry point for tibia nails is obtainable through suprapatellar or parapatellar approaches and to evaluate the most frequent injuries of the knee with these two approaches.
Vallier, Heather A
Displaced distal tibia shaft fractures are effectively treated with standard plates and intramedullary nails. Plate fixation performed with meticulous soft tissue handling results in minimal risks of infection and poor wound healing. Standard plates have high rates of primary union, whereas locking plates may delay union because of increased stiffness. Tibial healing may also be delayed after plating of the fibula, although fibula reduction and fixation may aid accuracy of reduction of the tibia. Malalignment occurs more often with infrapatellar intramedullary nailing versus plates, and early results of suprapatellar nailing appear promising in minimizing intraoperative malalignment. Long-term function after fixation of the distal tibia is good for most, with poor outcomes often associated with baseline social and mental health issues.
Reducing intraoperative duration and ionising radiation exposure during the insertion of distal locking screws of intramedullary nails: a small-scale study comparing the current fluoroscopic method against radiation-free, electromagnetic navigation.
Grimwood, Darren; Harvey-Lloyd, Jane
Intramedullary nailing is the standard surgical treatment for mid-diaphyseal fractures of long bones; however, it is also a high radiation dose procedure. Distal locking is regularly cited as a demanding element of the procedure, and there remains a reliance on X-ray fluoroscopy to locate the distal holes. A recently developed electromagnetic navigation (EMN) system allows radiation-free distal locking, with a virtual on-screen image. To compare operative duration, fluoroscopy time and radiation dose when using EMN over fluoroscopy, for the distal locking of intramedullary nails. Consecutive patients with mid-diaphyseal fractures of the tibia and femur, treatable with intramedullary nails, were prospectively enrolled during a 9-month period. The sample consisted of 29 individuals, 19 under fluoroscopic guidance and 10 utilising EMN. Participants were allocated depending on the type of intramedullary nail used and surgeon's preference. These were further divided into tibial and femoral subcategories, relative to the fracture site. EMN reduced fluoroscopy time by 49 (p = 0.038) and 28 s during tibial and femoral nailings, respectively. Radiation dose was reduced by 18 cGy/cm(2) (p = 0.046) during tibial and 181 cGy/cm(2) during femoral nailings when utilising EMN. Operative duration was 11 min slower during tibial nailings using EMN, but 38 min faster in respect of femoral nailings. This study has evidenced statistically significant reductions in both fluoroscopy time and radiation dose when using EMN for the distal locking of intramedullary nails. It is expected that overall operative duration would also decrease in line with similar studies, with increased usage and a larger sample.
Oh, Susan; Vandergriff, Travis
Scabies limited to the nail unit is quite unusual, but may persist after treatment of crusted scabies. We present a man with a history of crusted scabies that resolved with treatment, but later the patient reported a chronic problem with crumbly, thickened nails, which were found to be harboring scabies mites.
Suganthy, J; Rassau, Marina; Koshi, Rachel; Battacharjee, Suranjan
Congenital absence of tibia is a rare anomaly. We report a case of bilateral tibial hemimelia born to phenotypically normal parents. The two amputated legs with tibial dysplasia obtained from a 3-year-old boy were studied by radiography and anatomical dissection. The radiological evaluation revealed a normal hip joint. The lower end of femur was normal without any bifurcation, shortening or bowing. Fibula was present on both legs and there was no sign of bowing or doubling. Both right and left tibiae were absent. In addition, on the right side, five tarsal bones, two metatarsals and the corresponding digital rays were absent. On the left side, three tarsal bones were absent. Dissection of the amputated segments showed the presence of extensor digitorum longus, peroneus tertius, peroneus longus and brevis, gastrocnemius, and soleus. Following bilateral knee disarticulation the patient was fitted with prosthesis and is doing well.
Bertanha, Laura; Chiacchio, Nilton Di
Onychomycosis is the most prevalent onychopathy and it requires a correct early diagnosis. Currently, the diagnostic gold standard is the association of direct mycological test with culture; however, it shows variable sensitivity. The histopathological examination of the distal nail plate, called clipping, has shown to be an adjuvant in diagnosing onychomycosis. This is an easy-to-perform, relatively cheap examination that is little dependent of the examiner, rapidly provides results, has high sensitivity, and for patients it is painless and harmless. PMID:27828655
Cugat, Ramon; Ares, Oscar; Cuscó, Xavier; Garcia, Montserrat; Samitier, Gonzalo; Seijas, Roberto
Ankle arthroscopy provides a minimally invasive approach to the diagnosis and treatment of certain ankle disorders. Neurological complications resulting from ankle arthroscopy have been well documented in orthopaedic and podiatric literature. Owing to the superficial location of the ankle joint and the abundance of overlying periarticular neurovascular structures, complications reported in ankle arthroscopy are greater than those reported for other joints. In particular, all reported neurovascular injuries following ankle arthroscopy have been the direct result of distractor pin or portal placement. The standard posteromedial portal has recognized risks because of the proximity of the posterior neurovascular structures. There can be considerable variability in the course of these portals and their proximity to the neurovascular structures. We found one report of intra-articular damage to the posterior tibial nerve as a result of ankle arthroscopy in the English-language literature and we report this paper as a second case described in the literature.
Douglas R. Rammer; Samuel L. Zelinka
This study reviewed the literature on static and impact withdrawal of nails driven into the end grain of wood members. From this, an empirical relationship was created relating the specific gravity of the wood, the diameter of the nail, and the depth of penetration of the nail to the static withdrawal capacity of nails driven into the wood and withdrawn immediately....
Schemitsch, Emil H.; Bhandari, Mohit; Guyatt, Gordon; Sanders, David W.; Swiontkowski, Marc; Tornetta, Paul; Walter, Stephen D.; Zdero, Rad; Goslings, J.C.; Teague, David; Jeray, Kyle; McKee, Michael D.; Schemitsch, Emil H.; Bhandari, Mohit; Guyatt, Gordon; Sanders, David W.; Swiontkowski, Marc; Tornetta, Paul; Walter, Stephen D.; Zdero, Rad; Goslings, J.C.; Teague, David; Jeray, Kyle; McKee, Michael D.
Background: Prediction of negative postoperative outcomes after long-bone fracture treatment may help to optimize patient care. We recently completed the Study to Prospectively Evaluate Reamed Intramedullary Nails in Patients with Tibial Fractures (SPRINT), a large, multicenter trial of reamed and unreamed intramedullary nailing of tibial shaft fractures in 1226 patients. Using the SPRINT data, we conducted an investigation of baseline and surgical factors to determine any associations with an increased risk of adverse events within one year of intramedullary nailing. Methods: Using multivariable logistic regression analysis, we investigated fifteen baseline and surgical factors for any associations with an increased risk of negative outcomes. Results: There was an increased risk of negative events in patients with a high-energy mechanism of injury (odds ratio [OR] = 1.57; 95% confidence interval [CI], 1.05 to 2.35), a stainless steel compared with a titanium nail (OR = 1.52; 95% CI, 1.10 to 2.13), a fracture gap (OR = 2.40; 95% CI, 1.47 to 3.94), and full weight-bearing status after surgery (OR = 1.63; 95% CI, 1.00 to 2.64). There was no increased risk with the use of nonsteroidal anti-inflammatory agents, late or early time to surgery, or smoking status. Open fractures had a higher risk of events among patients treated with reamed nailing (OR = 3.26; 95% CI, 2.01 to 5.28) but not in patients treated with unreamed nailing (OR = 1.50; 95% CI, 0.92 to 2.47). Patients with open fractures who had wound management either without any additional procedures or with delayed primary closure had a decreased risk of events compared with patients who required subsequent, more complex reconstruction (OR = 0.18 [95% CI, 0.09 to 0.35] and 0.29 [95% CI, 0.14 to 0.62], respectively). Conclusions: We identified several baseline fracture and surgical characteristics that may increase the risk of adverse events in patients with tibial shaft fractures. Surgeons should consider the
Schemitsch, Emil H; Bhandari, Mohit; Guyatt, Gordon; Sanders, David W; Swiontkowski, Marc; Tornetta, Paul; Walter, Stephen D; Zdero, Rad; Goslings, J C; Teague, David; Jeray, Kyle; McKee, Michael D
Prediction of negative postoperative outcomes after long-bone fracture treatment may help to optimize patient care. We recently completed the Study to Prospectively Evaluate Reamed Intramedullary Nails in Patients with Tibial Fractures (SPRINT), a large, multicenter trial of reamed and unreamed intramedullary nailing of tibial shaft fractures in 1226 patients. Using the SPRINT data, we conducted an investigation of baseline and surgical factors to determine any associations with an increased risk of adverse events within one year of intramedullary nailing. Using multivariable logistic regression analysis, we investigated fifteen baseline and surgical factors for any associations with an increased risk of negative outcomes. There was an increased risk of negative events in patients with a high-energy mechanism of injury (odds ratio [OR] = 1.57; 95% confidence interval [CI], 1.05 to 2.35), a stainless steel compared with a titanium nail (OR = 1.52; 95% CI, 1.10 to 2.13), a fracture gap (OR = 2.40; 95% CI, 1.47 to 3.94), and full weight-bearing status after surgery (OR = 1.63; 95% CI, 1.00 to 2.64). There was no increased risk with the use of nonsteroidal anti-inflammatory agents, late or early time to surgery, or smoking status. Open fractures had a higher risk of events among patients treated with reamed nailing (OR = 3.26; 95% CI, 2.01 to 5.28) but not in patients treated with unreamed nailing (OR = 1.50; 95% CI, 0.92 to 2.47). Patients with open fractures who had wound management either without any additional procedures or with delayed primary closure had a decreased risk of events compared with patients who required subsequent, more complex reconstruction (OR = 0.18 [95% CI, 0.09 to 0.35] and 0.29 [95% CI, 0.14 to 0.62], respectively). We identified several baseline fracture and surgical characteristics that may increase the risk of adverse events in patients with tibial shaft fractures. Surgeons should consider the predictors identified in our analysis to inform
Background Flexible intramedullary nailing has emerged as an accepted procedure for paediatric femoral fractures. Present indications include all patients with femoral shaft fractures and open physis. Despite its excellent reported results, orthopaedic surgeons remain divided in opinion regarding its usefulness and the best material used for nails. We thus undertook a retrospective study of paediatric femoral fractures treated with titanium or stainless steel flexible nails at our institute with a minimum of 5 years follow up. Material and methods We included 73 femoral shaft fractures in 69 patients treated with retrograde flexible intramedullary nailing with a minimum follow up of 5 years. Final limb length discrepancy and any angular or rotational deformities were determined. Results Mean age at final follow up was 15.5 years (10-21 years). Mean follow up was 7.16 years (5.0-8.6 years). Titanium and stainless steel nails were used in 43 and 30 cases respectively. There were 51 midshaft, 17 proximal, and 5 distal fractures. All fractures united at an average of 11 weeks but asymptomatic malalignment and LLD were seen in 19% and 58% fractures respectively. LLD ranged from -3 cm to 1.5 cm. Other complications included superficial infection(2), proximal migration of nail(3), irritation at nail insertion site(5) and penetration of femoral neck with nail tip(1). There were 59 excellent, 10 satisfactory and 4 poor results. Conclusion Flexible intramedullary nailing is reliable and safe for treating paediatric femoral shaft fractures. It is relatively free of serious complications despite asymptomatic malalignment and LLD in significant percentage of fractures. PMID:22192682
Mandt, N; Blume-Peytavi, U
Human hair and nails, like all other organs, undergo chronological aging. Age-associated changes in growth, color, and structure of the hair and nails are common. In contrast to the aging process of the skin, the gerontobiological course of hair and nails has not been investigated comprehensively. Investigations on signaling pathways important for melanogenesis of the hair follicle improve our understanding of processes involved in hair greying. Differences in the structure and quality of the nails at an advanced age are determined mainly by age-dependent variations in lipid content of the nail plates. However, it is important to recognize age-dependent processes in hair shafts and nails and to distinguish between chronological aging and pathological changes. The possibilities to improve these aging processes have, primarily, to be seen in the field of external cosmetic procedures. Since the effect of preexisting hormonal substitution treatment has not yet been adequately investigated, it can be regarded as critical to evaluate the confirmed benefits and possible risks of such treatment either for hair or for nail quality improvement.
Jang, Ki-Mo; Lee, Jong-Hee; Park, Hyung-Jun; Kim, Jeong Lae; Han, Seung-Beom
This study involved 35 knees undergoing biplane medial open-wedge high tibial osteotomy (OWHTO) to assess the axial rotation of the distal tibia. The distal tibiae were internally rotated by 3.0° ± 7.1° after OWHTO. The opening width showed a Pearson correlation coefficient of -0.743 (P < .001), and the tuberosity osteotomy angle showed that of -0.678 (P < .001) with distal tibial rotation. However, changes in hip-knee-ankle angle, medial proximal tibial angle, and posterior tibial slope were not significantly correlated with the change in distal tibial rotation. In conclusion, there was an unintended tendency of increasing internal rotation of the distal tibia after biplane medial OWHTO, and this tendency was positively related to the opening width and tuberosity osteotomy angle. Copyright © 2016 Elsevier Inc. All rights reserved.
van Haeff, M J; Sauter, A J
Eight weeks after transposition of the tibial tubercle for recurrent subluxation of the patella, the patient sustained a tibial fracture during rope jumping. In spite of consolidation of the osteotomy in the frontal plane, there remained a small gap in the anterior cortex in the transverse plane through which the tibia failed during bending stress.
Background and purpose In the last decade, intramedullary limb lengthening has become a viable alternative to traditional external systems. We retrospectively analyzed the use of an intramedullary motorized nail (Fitbone) in a consecutive series of 32 patients. Patients and methods During the period September 2006 to December 2008, 32 consecutive patients with a median age of 17 (IQR: 15–19) years were treated with a fully implantable, motorized intramedullary lengthening device (Fitbone). The median leg length discrepancy was 35 (IQR: 30–44) mm at the femur (n = 21) and 28 (IQR: 25–30) mm at the tibia (n = 11). Results Leg lengthening was successful in 30 of 32 cases, with no residual relevant discrepancy (± 5 mm). No intraoperative complications were observed. The consolidation index was significantly different (p = 0.04) between femoral lengthening (mean 35 days/cm) and tibial lengthening (mean 48 days/cm) but did not depend on age older/younger than 16 or previous operations at the affected site. 3 problems, 3 obstacles, and 4 complications (3 minor, 1 major) were encountered in 8 patients, 5 of which were implant-associated. Interpretation This technique even allows correction in patients with multiplanar deformities. Compared to external devices, intramedullary systems provide comfort and reduce complication rates, give improved cosmetic results, and lead to fast rehabilitation since percutaneous, transmuscular fixation is prevented. This results in reasonable overall treatment costs despite the relatively high costs of implants. PMID:21561309
Tsourvakas, Stefanos; Alexandropoulos, Christos; Papachristos, Ioannis; Tsakoumis, Grigorios; Ameridis, Nikolaos
Antegrade interlocked humeral nailing for stabilization of humeral fractures was introduced many years ago, and studies on this method in the orthopedic literature have shown mixed results. The purpose of this investigation was to document the clinical outcome and complications associated with the use of an antegrade intramedullary nail (T2, Stryker) for the humeral fractures. Between 2005 and 2008, 52 fractures of the humeral shaft were treated operatively with this intramedullary nail in our department. Eight patients were polytraumatized, and four patients had an open fracture. The mean age of patients was 51.7 years. Forty-eight patients had an adequate duration of clinical follow-up (a mean of 18 months) for analysis. Complications were recorded, and the time to union was measured. Shoulder and elbow functions were assessed using the Constant Score and the Morrey Score, respectively. Forty-six fractures healed, with a mean time to clinical union of 10.3 weeks. Two patients developed pseudarthroses. There were four adverse events: two proximal screws backed out, one superficial infection at the insertion point, and one fracture at the distal end of the nail. Ninety-one percentage of patients had an excellent or good shoulder function. Five further operations were necessary: two for treatment of pseudarthroses, two for removal the backed out proximal screws, and one wound debridement for superficial infection. Antegrade humeral nailing is a valid therapeutic option for stabilization of humeral shaft fractures. By strictly adhering to the operation technique, the number and the severity of complications can be reduced. When good fracture alignment and stability are obtained, uneventful bone healing with good functional results is the rule.
Yang, Jui-Yung; Yang, Shih-Yi; Chen, Wei F
Nail fold deformities from burn injury frequently result in eponychial retraction, proximal nail exposure, pain, and distal phalangeal function impairment. Secondary nail abnormalities including longitudinal ridges, surface cracks, and fragility are common sequelae to nail fold deformities. Surgical management of postburn nail fold deformity is challenging because of scar contractures involving the dorsum of digits and lack of surrounding healthy tissues that can be used as source of soft tissue for reconstruction. Previous reports have discussed several methods for reconstruction of these deformities. However, all of these methods are associated with significant donor site morbidities. From August 2008 to January 2010, "onion" flap reconstruction was performed for postburn nail fold contractures and deformities on 32 fingers of eight patients (five men and three women; average age, 44.4 years; age range, 23-54 years). This novel technique was used to release scar contractures in the eponychial area and allow soft tissue restoration by redraping the eponychium in a single-step procedure. All 32 fingers received single-stage "onion" flap reconstruction for their nail fold deformities at least 6 months after the initial injury. The follow-up period, with an average of 7.8 months, revealed that all nails had good esthetic and functional results. All experienced amelioration of nail abnormalities. The "onion" advancement flap had effectively released the scar contracture around the nail fold and simultaneously restored the eponychial fold. The "onion" flap technique provides superior results compared with those from conventional techniques. We recommend it as the mainstay of treatment for reconstruction of the postburn eponychial deformities. V, therapeutic study.
Shah, Krupa; Shah, Hitesh
Tibial hemimelia is a rare congenital limb deficiency which is characterised by a hypoplastic/aplastic tibia. It actually represents a spectrum of anomalies, ranging from mild hypoplasia of the tibia to total absence of the tibia. Several classifications based on radiological description exist in the literature. The tibial hemimelia is usually described with preaxial mirror polydactyly, split hand/foot syndrome-ectrodactyly, polydactyly-triphalangeal thumb syndrome (Werner syndrome) and micromelia-trigonal brachycephaly syndrome. We describe a child with unclassified tibial hemimelia. The child had right incomplete tibial hemimelia with bifid tibia, left complete tibial hemimelia, bilateral split hands and left split foot. This is the first report of the bifid tibia in the literature.
Kapoor, Sudhir K; Kataria, Himanshu; Boruah, Tankeswar; Patra, Satya R; Chaudhry, Aashish; Kapoor, Saurabh
Intramedullary fixation is the treatment of choice for closed diaphyseal fractures of femur and tibia. The axial and rotational stability of conventional interlocking nails depends primarily on locking screws. This method uses increased operating time and increased radiation exposure. An intramedullary implant that can minimize these disadvantages is obviously better. Expandable intramedullary nail does not rely on interlocking screws and achieves axial and rotational stability on hydraulic expansion of the nail. We analyzed 32 simple fractures of shaft of femur and tibia treated by self-locking expandable nail. Intramedullary fixation was done by using self-locking, expandable nail in 32 patients of closed diaphyseal fractures of tibia (n = 10) and femur (n = 22). The various modes of injury were road traffic accidents (n = 21), fall from height (n = 8), simple fall (n = 2), and pathological fracture (n = 1). Among femoral diaphyseal fractures 16 were males and six females, average age being 33 yrs (range, 18- 62 yrs). Seventeen patients had AO type A (A1 (n = 3), A2 (n = 4), A3 (n = 10)) and 5 patients had AO type B (B1 (n = 2), B2 (n = 2), B3 (n = 1)) fractures. Eight patients having tibial diaphyseal fractures were males and two were females; average age was 29.2 (range, 18- 55 yrs). Seven were AO type A (A1 (n = 2), A2 (n = 3), A3 (n = 2)) and three were AO type B (B1 (n = 1), B2 (n = 1), and B3 (n = 1)). We performed closed (n = 27) or open reduction (n = 5) and internal fixation with expandable nail to stabilize these fractures. The total radiation exposure during surgery was less as no locking screws were required. Early mobilisation and weight-bearing was started depending on fracture personality and evidences of healing. Absence of localised tenderness and pain on walking was considered clinical criteria for union, radiographic criteria of union being continuity in at least in three cortices in both AP and lateral views. Patients were followed for at
Kapoor, Sudhir K; Kataria, Himanshu; Boruah, Tankeswar; Patra, Satya R; Chaudhry, Aashish; Kapoor, Saurabh
Background: Intramedullary fixation is the treatment of choice for closed diaphyseal fractures of femur and tibia. The axial and rotational stability of conventional interlocking nails depends primarily on locking screws. This method uses increased operating time and increased radiation exposure. An intramedullary implant that can minimize these disadvantages is obviously better. Expandable intramedullary nail does not rely on interlocking screws and achieves axial and rotational stability on hydraulic expansion of the nail. We analyzed 32 simple fractures of shaft of femur and tibia treated by self-locking expandable nail. Materials and Methods: Intramedullary fixation was done by using self-locking, expandable nail in 32 patients of closed diaphyseal fractures of tibia (n = 10) and femur (n = 22). The various modes of injury were road traffic accidents (n = 21), fall from height (n = 8), simple fall (n = 2), and pathological fracture (n = 1). Among femoral diaphyseal fractures 16 were males and six females, average age being 33 yrs (range, 18- 62 yrs). Seventeen patients had AO type A (A1 (n = 3), A2 (n = 4), A3 (n = 10)) and 5 patients had AO type B (B1 (n = 2), B2 (n = 2), B3 (n = 1)) fractures. Eight patients having tibial diaphyseal fractures were males and two were females; average age was 29.2 (range, 18- 55 yrs). Seven were AO type A (A1 (n = 2), A2 (n = 3), A3 (n = 2)) and three were AO type B (B1 (n = 1), B2 (n = 1), and B3 (n = 1)). We performed closed (n = 27) or open reduction (n = 5) and internal fixation with expandable nail to stabilize these fractures. The total radiation exposure during surgery was less as no locking screws were required. Early mobilisation and weight-bearing was started depending on fracture personality and evidences of healing. Absence of localised tenderness and pain on walking was considered clinical criteria for union, radiographic criteria of union being continuity in at least in three cortices in both AP and lateral views
Tokunaga, Susumu; Rogge, Renee D; Small, Scott R; Berend, Michael E; Ritter, Merrill A
Prosthetic alignment, patient characteristics, and implant design are all factors in long-term survival of total knee arthroplasty (TKA), yet the level at which each of these factors contribute to implant loosening has not been fully described. Prior clinical and biomechanical studies have indicated tibial overload as a cause of early TKA revision. The purpose of this study was to determine the relationship between tibial component design and bone resection on tibial loading. Finite-element analysis (FEA) was performed after simulated implantation of metal backed (MB) and all-polyethylene (AP) TKA components in 5 and 15 mm of tibial resection into a validated intact tibia model. Proximal tibial strains significantly increased between 13% and 199% when implanted with AP components (p < 0.05). Strain significantly increased between 12% and 209% in the posterior tibial compartment with increased bone resection (p < 0.05). This study indicates elevated strains in AP implanted tibias across the entirety of the proximal tibial cortex, as well as a posterior shift in tibial loading in instances of increased resection depth. These results are consistent with trends observed in prior biomechanical studies and may associate the documented device history of tibial collapse in AP components with increased bone strain and overload beneath the prosthesis.
Le Fourn, E; Duhard, E; Tauveron, V; Maruani, A; Samimi, M; Lorette, G; Vaillant, L; Machet, L
Secondary lymphoedema is characterized by lymphatic stasis that is often the result of a lymph node lesion. At advanced stages it may cause trophic changes in the skin. However, the presence of changes in the nail unit has not been reported to date. The aim of this study was to determine the presence of nail abnormalities in cases of secondary lymphoedema. This was a prospective study, conducted on patients with unilateral secondary lymphoedema. A comparative clinical and dermoscopic examination and 20-MHz high-resolution ultrasound imaging of the affected limb and the contralateral limb were performed. Thirty-three patients were included. On physical examination, hyperkeratosis of the lateral nail folds, friability of the nail surface, 'ragged' proximal nail folds and cuticle and apparent leuconychia were observed more frequently on the lymphoedematous limb. The ultrasound study of the nails of the thumb and the big toe did not reveal any differences in thickness of the different structures of the nail between the lymphoedema side and the opposite side. The nail matrix was longer on the lymphoedema side. Our study showed mild changes in the nail unit compatible with the xerosis often associated with severe lymphoedema. However, the study also showed frequent evidence of 'ragged' cuticles, which in these patients at high risk of erysipelas are entry points for bacteria. This should be taken into account when counselling patients with limb lymphoedema in order to prevent erysipelas. © 2011 The Authors. BJD © 2011 British Association of Dermatologists.
Eisenstein, Emmanuel D.; Rodriguez, Mario
Introduction. Ankle arthrodesis is performed in a variety of methods. We propose a new technique for tibiotalar arthrodesis using a newly designed intramedullary nail. Methods. We proposed development of an intramedullary device for ankle arthrodesis which spared the subtalar joint using a sinus tarsi approach. Standard saw bones models and computer assisted modeling and stress analysis were used to develop different nail design geometries and determine the feasibility of insertion. After the final design was constructed, the device was tested on three cadaveric specimens. Results. Four basic nail geometries were developed. The optimal design was composed of two relatively straight segments, each with a different radius of curvature for their respective tibial and talar component. We successfully implemented this design into three cadaveric specimens. Conclusion. Our newly designed tibiotalar nail provides a new technique for isolated tibiotalar fusion. It utilizes the advantages of a tibiotalar calcaneal nail and spares the subtalar joint. This design serves as the foundation for future research to include compression options across the tibiotalar joint and eventual transition to clinical practice. PMID:27818800
Yim, Ji Hyeon; Seon, Jong Keun; Song, Eun Kyoo
Although opening-wedge high tibial osteotomy (HTO) is used to correct deformities, it can simultaneously alter tibial slope in the sagittal plane because of the triangular configuration of the proximal tibia, and this undesired change in tibial slope can influence knee kinematics, stability, and joint contact pressure. Therefore, medial opening-wedge HTO is a technically demanding procedure despite the use of 2-dimensional (2-D) navigation. The authors evaluated the posterior tibial slope pre- and postoperatively in patients who underwent navigation-assisted opening-wedge HTO and compared posterior slope changes for 2-D and 3-dimensional (3-D) navigation versions. Patients were randomly divided into 2 groups based on the navigation system used: group A (2-D guidance for coronal alignment; 17 patients) and group B (3-D guidance for coronal and sagittal alignments; 17 patients). Postoperatively, the mechanical axis was corrected to a mean valgus of 2.81° (range, 1°-5.4°) in group A and 3.15° (range, 1.5°-5.6°) in group B. A significant intergroup difference existed for the amount of posterior tibial slope change (Δ slope) pre- and postoperatively (P=.04).Opening-wedge HTO using navigation offers accurate alignment of the lower limb. In particular, the use of 3-D navigation results in significantly less change in the posterior tibial slope postoperatively than does the use of 2-D navigation. Accordingly, the authors recommend the use of 3-D navigation systems because they provide real-time intraoperative information about coronal, sagittal, and transverse axes and guide the maintenance of the native posterior tibial slope. Copyright 2012, SLACK Incorporated.
Salonen, A; Lahdes-Vasama, T; Mattila, V M; Välipakka, J; Pajulo, O
Despite several potential complications of elastic intramedullary nailing, it is currently the treatment of choice for femoral diaphyseal fractures in school-aged children. This study aimed to critically evaluate the complications of titanium elastic nailing in pediatric femoral shaft fractures. This study evaluated patients with a diaphyseal femoral fracture treated with titanium elastic nailing (TEN) in Tampere University Hospital in Finland. The study group included 32 children with a mean age of 9 years during a 5-year period, from 1 January 2003 to 31 December 2007. Data were collected from medical records and x-rays. Mean follow-up time was 42 months. Of 32 patients, 9 (28%) reported a postoperative complication. Complications were associated with nail prominence in five (16%) patients and instability in four (12%) patients. In patients with nail prominence, the titanium elastic nailing-nail ends were unbent and 10-35 mm outside the cortex of the distal femur. The nail prominence caused pain and delayed knee mobilization until the nail was removed after a mean time of 4 months. In patients with fracture instability, the mean titanium elastic nailing-nail/medullary canal diameter ratio was 46% and periosteal callus formation was 5.4 mm at the first control. In those with stable fractures, the values were 66% and 9.2 mm, respectively. Based on this study, two types of pitfalls in a small volume center were found. Titanium elastic nail ends were left unbent and too long. We recommend palpating the nail ends to exclude nail prominence and to verify free movement of the knee after nail cutting and bending. Fracture instability was caused by inserting titanium elastic nailing-nails that were too narrow. To avoid this complication, careful preoperative planning to select the proper-size titanium elastic nailing-nails and intraoperative testing of fracture stability under continuous fluoroscopy after the operation is advised. © The Finnish Surgical Society 2014.
A, Joshi; Kc, B R; Basnet, S B; Panth, R; Shrestha, R L; Chand, P; Thapa, B B
Adamantinoma is an extremely rare primary bony neoplasm. Because of its malignant nature, accurate and early diagnosis is very important. On the other hand adamantinoma mimics many benign conditions, so it is doubly important to establish correct tissue diagnosis to avoid radical surgery with morbidities. Because of its rarity, diagnosing adamantinoma still remains difficult, even if when it occurs in classical sites. We report a case of adamantinoma of tibial shaft diaphysis in a 23 year male. In this case, because of classic clinic-radiological features, we were suspecting adamantinoma from very beginning but final diagnosis was delayed for nine months.
Tsang, S T J; Mills, L A; Frantzias, J; Baren, J P; Keating, J F; Simpson, A H R W
The aim of this study was to identify risk factors for the failure of exchange nailing in nonunion of tibial diaphyseal fractures. A cohort of 102 tibial diaphyseal nonunions in 101 patients with a mean age of 36.9 years (15 to 74) were treated between January 1992 and December 2012 by exchange nailing. Of which 33 (32%) were initially open injuries. The median time from primary fixation to exchange nailing was 6.5 months (interquartile range (IQR) 4.3 to 9.8 months). The main outcome measures were union, number of secondary fixation procedures required to achieve union and time to union. Univariate analysis and multiple regression were used to identify risk factors for failure to achieve union. Multiple causes for the primary nonunion were found for 28 (27%) tibiae, with infection present in 32 (31%). Six patients were lost to follow-up. Further surgical procedures were required in 35 (36%) nonunions. Other fixation modalities were required in five fractures. A single nail exchange procedure achieved union in 60/96 (63%) of all nonunions. Only 11 out of 31 infected nonunions (35.4%) healed after one exchange nail procedure. Up to five repeated exchange nailings, with or without bone grafting, ultimately achieved union in 89 (93%) fractures. The median time to union after exchange nailing was 8.7 months (IQR 5.7 to 14.0 months). Univariate analysis confirmed that an oligotrophic/atrophic pattern of nonunion (p = 0.002), a bone gap of 5 mm or more (p = 0.04) and infection (p < 0.001), were predictive for failure of exchange nailing Multiple regression analysis found that infection was the strongest predictor of failure (p < 0.001). Exchange nailing is an effective treatment for aseptic tibial diaphyseal nonunion. However, in the presence of severe infection with a highly resistant organism, or extensive sclerosis of the bone, other fixation modalities, such as Ilizarov treatment, should be considered. Exchange nailing is an effective treatment for aseptic tibial
... medlineplus.gov/news/fullstory_167455.html When Is It Nail Fungus? Dermatologist says only an expert can ... but you shouldn't be embarrassed to discuss it with a board-certified dermatologist, who can help ...
Patsatsi, A; Sotiriou, E; Devliotou-Panagiotidou, D; Sotiriadis, D
A 60-year-old woman presented with painful erosions in the oral mucosa, pharynx, perineum and perianal area, and multiple plaques with thick adherent crusts on the scalp. Most (nine) of the patient's fingernails had alterations in colour, affecting more than half of the nail plate, and all the toenails had severe inflammation of the nail folds, haemorrhagic paronychia and subungual or intraungual haemorrhage. A diagnosis of pemphigus vulgaris (PV) was made based on histology and on direct and indirect immunofluorescence findings. Groups of acantholytic cells were also observed in a Tzanck smear obtained from a subungual lesion. Onychomadesis in most of the fingernails and in all the toenails developed gradually. The patient was hospitalized and treated with oral corticosteroids. Complete recovery without residual damage to the nails and persistent remission was achieved. Nail involvement in PV is rarely described and is always of interest, as its presentation varies widely.
Purpose Rigid interlocking nailing for femoral shaft fracture is ideal for use in adolescents in terms of stability of the fracture and convenience for the patient. However, numerous authors have reported that rigid interlocking nailing has some limitations in this age group due to the risk of complications. We evaluated the results of intramedullary nailing for femoral shaft fractures with an interlocking humeral nail in older children and adolescents. Materials and Methods We retrospectively reviewed records of patients treated with an interlocking humeral nail. Radiographs were examined for proximal femoral change and evidence of osteonecrosis. Outcomes were assessed by major or minor complications that occurred after operative treatment. Results Twenty-four femoral shaft fractures in 23 patients were enrolled. The mean age at the time of operation was 12 years and 8 months and the mean follow-up period was 21 months. Bony union was achieved in all patients without any complications related to the procedure such as infection, nonunion, malalignment and limb length discrepancy. All fractures were clinically and radiographically united within an average eight weeks. No patients developed avascular necrosis of the femoral head and coxa valga. Conclusion Intramedullary nailing through the greater trochanter using a rigid interlocking humeral nail is effective and safe for the treatment of femoral shaft fractures in older children and adolescents. PMID:22318831
Garnavos, C; Seaton, J; Lunn, P G
The True-Flex nail was used in 23 selected non-pathological and eight pathological fractures/lesions of the humeral shaft. The overall fracture union rate was 69.5 per cent and the patients achieved a good range of movement of the shoulder and elbow. Nailing did not lead to union of established non-unions or fractures which were previously treated unsuccessfully by surgery despite bone grafting. All patients with pathological fractures/lesions regained good function of the arm and a good range of movement of the shoulder and the elbow. In one case the nail migrated proximally and impinged on the rotator cuff. This was revised. No other technical difficulties or complications were seen. The True-Flex nail is useful in the treatment of difficult and relatively recent humeral shaft fractures. Established non-unions or cases where previous surgery has failed should be treated by alternative methods.
Silverman, Eric R.; Vydyanathan, Amaresh; Gritsenko, Karina; Shaparin, Naum; Singh, Nair; Downie, Sherry A.
Background. A recently described selective tibial nerve block at the popliteal crease presents a viable alternative to sciatic nerve block for patients undergoing total knee arthroplasty. In this two-part investigation, we describe the effects of a tibial nerve block at the popliteal crease. Methods. In embalmed cadavers, after the ultrasound-guided dye injection the dissection revealed proximal spread of dye within the paraneural sheath. Consequentially, in the clinical study twenty patients scheduled for total knee arthroplasty received the ultrasound-guided selective tibial nerve block at the popliteal crease, which also resulted in proximal spread of local anesthetic. A sensorimotor exam was performed to monitor the effect on the peroneal nerve. Results. In the cadaver study, dye was observed to spread proximal in the paraneural sheath to reach the sciatic nerve. In the clinical observational study, local anesthetic was observed to spread a mean of 4.7 + 1.9 (SD) cm proximal to popliteal crease. A negative correlation was found between the excess spread of local anesthetic and bifurcation distance. Conclusions. There is significant proximal spread of local anesthetic following tibial nerve block at the popliteal crease with possibility of the undesirable motor blocks of the peroneal nerve. PMID:28260964
Albers, James; Lowe, Brian; Lipscomb, Hester; Hudock, Stephen; Dement, John; Evanoff, Bradley; Fullen, Mark; Gillen, Matt; Kaskutas, Vicki; Nolan, James; Patterson, Dennis; Platner, James; Pompeii, Lisa; Schoenfisch, Ashley
Use of a pneumatic nail gun with a sequential actuation trigger (SAT) significantly diminishes the risk for acute traumatic injury compared to use of a contact actuation trigger (CAT) nail gun. A theoretically-based increased risk of work-related musculoskeletal disorders from use of a SAT nail gun, relative to CAT, appears unlikely and remains unproven. Based on current knowledge, the use of CAT nail guns cannot be justified as a safe alternative to SAT nail guns. This letter provides a perspective of ergonomists and occupational safety researchers recommending the use of the sequential actuation trigger for all nail gun tasks in the construction industry.
Albers, James; Lipscomb, Hester; Hudock, Stephen; Dement, John; Evanoff, Bradley; Fullen, Mark; Gillen, Matt; Kaskutas, Vicki; Nolan, James; Patterson, Dennis; Platner, James; Pompeii, Lisa; Schoenfisch, Ashley
Summary Use of a pneumatic nail gun with a sequential actuation trigger (SAT) significantly diminishes the risk for acute traumatic injury compared to use of a contact actuation trigger (CAT) nail gun. A theoretically-based increased risk of work-related musculoskeletal disorders from use of a SAT nail gun, relative to CAT, appears unlikely and remains unproven. Based on current knowledge, the use of CAT nail guns cannot be justified as a safe alternative to SAT nail guns. This letter provides a perspective of ergonomists and occupational safety researchers recommending the use of the sequential actuation trigger for all nail gun tasks in the construction industry. PMID:26366020
Lakhwani, O. P.
Background. Selection of entry point for nail insertion is controversial and lack firm anatomical basis. The study is done to analyze the proximal anthropometry of femur and measure the Trochanter-Shaft Angle to find its relation and significance in selection of entry point for antegrade uniplanar femoral nail. Materials and Methods. Study involves the measurement of trochanter-shaft angle and other anthropometric measurements on 50 dry femora and on digital radiogram. Results. Trochanter-Shaft angle ranges between 5–17 degrees in anthropometric study and 4–14 degrees in radiological study. Over all in 27 cases (54%), exit points of reamur fall in the middle quadrant in sagittal and coronal plane, which corresponds to the T-S angle of 6–12 degrees. Discussion and Conclusion. Proximal femoral Anthropometry and Trochanter-shaft angle is variable; hence it is difficult to fix any anatomical point as a universal entry point for antegrade femoral nail insertion. Trochanter shaft angle (TSA) can be well accessed radiologically and serve as a guide for selection of proper entry point.for safe nail insertion. Clinical Relevance. Individual variations in the proximal femur anatomy for safe nail insertion can be correlated with Trochanter shaft angle to serve safe entry site. PMID:24977077
Goodbody, Christine M; Lee, Rushyuan J; Flynn, John M; Sankar, Wudbhav N
Elastic nailing is a common method of fixation for tibial shaft fractures in skeletally immature individuals. Poor outcomes of titanium elastic nails for femoral shaft fractures have been associated with increasing patient age and weight, especially patients weighing >50 kg. Our objective is to determine if there is an upper weight or age limit to the safe and effective use of titanium elastic nails for tibial shaft fractures in the pediatric population. This is a retrospective cohort study of patients who underwent stabilization of a tibial shaft fracture with titanium elastic nails at a large tertiary-care pediatric trauma center. Data collected included patient demographics, injury characteristics, and radiographic data. Weight groups were stratified as ≥ or <50 kg, and age groups as 14 years or older or less than 14 years old. Malunion was defined as 10 degrees of angulation in either the sagittal or coronal plane. Union was defined as bridging of ≥3 cortices on orthogonal radiographs. A significant difference in time to union was considered to be 3 weeks. Ninety-five patients were included with a mean age of 12.1 years (range, 6 to 16 y) and a mean weight of 50.2 kg (range, 21 to 122 kg). Malunion rate was similar between weight cohorts: 13.3% (6/45) in the ≥50-kg group and 10% (5/50) in the <50-kg group (P=0.61). Malunion rate was similarly comparable between age groups: 17.6% (6/34) in the 14 years and older group and 8.2% (5/61) in the less than 14-year-old group (P=0.17). There was no statistically significant difference in time to union between weight or age cohorts. In sum, we did not find a significant difference in the rate of malunion or time to healing between younger and older patients or between lighter and heavier patients. The use of titanium elastic nails for tibial shaft fractures, unlike for other long bone fractures, seems not to be precluded in older and heavier patients. Level III.
Parker, M J; Handoll, H H
Cephalocondylic intramedullary nails which are inserted proximally to distally (cephalocondylic) have been used for the surgical treatment of extracapsular hip fractures. To update and expand our review comparing the Gamma nail with the sliding hip screw (SHS) by comparing all cephalocondylic intramedullary nails with extramedullary implants for the surgical treatment of extracapsular hip fractures in adults. We searched the Cochrane Musculoskeletal Injuries Group trials register, Medline, select orthopaedic journals and conference proceedings, and reference lists of relevant articles. We contacted trialists, colleagues and implant manufacturers. Date of the most recent search: June 1998. All randomised and quasi-randomised trials comparing cephalocondylic nails with extramedullary implants for extracapsular hip fractures. Both reviewers independently assessed trial quality and extracted data. Additional information was sought from all trialists. Wherever appropriate and possible, results were pooled. The one trial of 230 patients comparing the Kuntscher-Y nail with the SHS, reported no major difference the outcome aside from a significantly increased number of patients with leg shortening, and a tendency for poorer recovery of mobility in the Kuntscher-Y nail group. Fourteen trials comparing the Gamma nail with the SHS were included, with data available for 1977 patients. The Gamma nail was associated with an increased risk of operative and later fracture of the femur and an increased re-operation rate. There were no major differences in the incidence of wound infection, mortality or medical complications between implants. Data were inadequate to determine if there were differences for other outcomes. Two trials involving 231 patients compared the intramedullary hip screw (IMHS) with the SHS. Fracture fixation complications were more common in the IMHS group: all cases of operative and later fracture of the femur and haematoma occurred in this group. Results for
Garlock, Adam N; Donovan, Jim; LeCronier, David J; Houghtaling, John; Burton, Stephen; Atkinson, Patrick J
Intramedullary nailing has evolved to become the standard of care for most diaphyseal femoral and tibial fractures, as well as an expanding number of metaphyseal fractures. Owing to the unstable nature of some fractures, the intramedullary device may be subjected to significant stresses owing to a lack of solid cortical contact after nailing. In such cases, excessive interfragmentary motion (due to construct toggle) has been shown to occur. Such motion increases the likelihood of a non- or delayed-union. In the current study, two versions of a modified, angle stable interlocking design were subjected to fatigue testing in a segmental defect fracture model representing a canine femur. As a control, a third group of constructs were stabilized with a traditional nail that allowed a small amount of toggle. All constructs were subjected to 50,000 fatigue cycles representing 12 weeks of cage activity at physiologic levels of combined axial-torsional loading. Torsional testing pre- and post-fatigue revealed 4.6 +/- 1.3 degrees of toggle in the traditional nail and no toggle with the angle stable nail designs. The stable nails were also significantly stiffer in axial compression and torsion before and after cycling. These data indicate that the enhanced stability of the modified interlocking designs can be maintained throughout fatigue cycling in a challenging fracture model.
Zhou, Zhentao; Zhou, Xiaozhong; Shan, Bingchen; Zhou, Haibin; Lu, Zhengfeng; Dong, Qirong
To describe the applications and effects of electromagnetic navigation (EN) technology in distal locking for the treatment of long diaphyseal fracture (LDF) with interlocking intramedullary nailing (IIN). An interventional study. The Second Affiliated Hospital of Soochow University, China, from March 2013 to July 2014. Patients who underwent IIN-LDF were selected. Twenty-four (50%) of whom were operated under EN guidance (group A) and the other 24 (50%) under conventional targeting guidance (group B). The distal locking time and X-ray irradiation time of the two groups were compared. Each group included 16 (33.3%) cases of femoral fracture and 8 (16.7%) cases of tibial fracture. The success rate of distal locking in group A was higher than that in group B (95.8% vs. 83.3%, p=0.045). There were statistically significant differences in the distal locking time and X-ray irradiation time of femoral intramedullary nailing between the two groups (p=0.027 and p=0.001, respectively). There were no statistically significant differences in the distal locking time and X-ray irradiation time of tibial intramedullary nailing between the two groups (p=0.347 and p=0.056, respectively). EN-IN was advantageous as it enabled easy targeting, significantly reduced intraoperative fluoroscopy and operation time and small trauma and had other advantages when used for treating LDFs, especially femoral diaphyseal fractures.
Rauch, Cyril; Cherkaoui-Rbati, Mohammed
Although surgical treatment of nail conditions can be traced back centuries to the writings of Paul Aegineta (625-690 AC), little is known about the physical laws governing nail growth. Such a poor understanding together with the increasing number of nail salons in the high street should raise legitimate concerns regarding the different procedures applied to nails. An understanding of the physics of nail growth is therefore essential to engage with human medicine and to understand the aetiology of nail conditions. In this context, a theory of nail plate adhesion, including a physical description of nail growth can be used to determine the transverse and longitudinal curvatures of the nail plate that are so important in the physical diagnosis of some nail conditions. As a result physics sheds light on: (a) why/how nails/hooves adhere strongly, yet grow smoothly; (b) why hoof/claw/nail growth rates are similar across species; (c) potential nail damage incurred by poor trimming; (d) the connection between three previously unrelated nail conditions, i.e. spoon-shaped, pincer and ingrown nails and; last but not least, (e) why ingrown nails occur preferentially in the big toes.
Shadgan, Babak; Pereira, Gavin; Menon, Matthew; Jafari, Siavash; Darlene Reid, W; O'Brien, Peter J
We sought to examine the occurrence of acute compartment syndrome (ACS) in the cohort of patients with tibial diaphyseal fractures and to detect associated risk factors that could predict this occurrence. A total of 1,125 patients with tibial diaphyseal fractures that were treated in our centre were included into this retrospective cohort study. All patients were treated with surgical fixation. Among them some were complicated by ACS of the leg. Age, gender, year and mechanism of injury, injury severity score (ISS), fracture characteristics and classifications and the type of fixation, as well as ACS characteristics in affected patients were studied. Of the cohort of patients 772 (69 %) were male (mean age 39.60 ± 15.97 years) and the rest were women (mean age 45.08 ± 19.04 years). ACS of the leg occurred in 87 (7.73 %) of all tibial diaphyseal fractures. The mean age of those patients that developed ACS (33.08 ± 12.8) was significantly lower than those who did not develop it (42.01 ± 17.3, P < 0.001). No significant difference in incidence of ACS was found in open versus closed fractures, between anatomic sites and following IM nailing (P = 0.67). Increasing pain was the most common symptom in 71 % of cases with ACS. We found that younger patients are definitely at a significantly higher risk of ACS following acute tibial diaphyseal fractures. Male gender, open fracture and IM nailing were not risk factors for ACS of the leg associated with tibial diaphyseal fractures in adults. Level IV.
Stanisław, Bołtuć Witold; Bogusław, Golec Edward
Background: The work presents the assessment of the results of treatment of open tibial shaft fractures in polytrauma patients. Materials and Methods: The study group comprised 28 patients who underwent surgical treatment of open fractures of the tibial shaft with locked intramedullary nailing. The mean age of the patients was 43 years (range from 19 to 64 years). The criterion for including the patients in the study was concomitant multiple trauma. For the assessment of open tibial fractures, Gustilo classification was used. The most common concomitant multiple trauma included craniocerebral injuries, which were diagnosed in 12 patients. In 14 patients, the surgery was performed within 24 h after the injury. In 14 patients, the surgery was delayed and was performed 8–10 days after the trauma. Results: The assessment of the results at 12 months after the surgery included the following features: time span between the trauma and the surgery and complications in the form of osteomyelitis and delayed union. The efficacy of gait, muscular atrophy, edema of the operated limb and possible disturbances of its axis were also taken under consideration. In patients operated emergently within 24 h after the injury, infected nonunion was observed in three (10.8%) males. These patients had grade III open fractures of the tibial shaft according to Gustilo classification. No infectious complications were observed in patients who underwent a delayed operation. Conclusion: Evaluation of patients with open fractures of the tibial shaft in multiple trauma showed that delayed intramedullary nailing performed 8–10 days after the trauma, resulted in good outcome and avoided development of delayed union and infected nonunion. This approach gives time for stabilization of general condition of the patient and identification of pathogens from wound culture. PMID:19753226
Schons, Karen Regina Rosso; Knob, Cristiane Faccin; Murussi, Nádia; Beber, André Avelino Costa; Neumaier, Walter; Monticielo, Odirlei André
Nails are considered epidermal appendages, and as such, are commonly affected in patients with psoriasis, 80% of whom are likely to develop nail psoriasis as a result of their condition. Two patterns of nail disorders have been shown to be caused by psoriasis. Nail matrix involvement can result in features such as leukonychia, pitting (punctures or cupuliform depressions), red spots in the lunula and crumbling. Nail bed involvement, on the other hand, can cause onycholysis, salmon or oil-drop patches, subungual hyperkeratosis and splinter hemorrhages. Nail disease causes aesthetic and functional impairment, and is indicative of more severe forms of psoriasis as well as of joint involvement. The treatment for nail psoriasis involves behavioral interventions, topical medications, or systemic therapy in case of extensive skin or joint involvement. This article presents a review of the main features of nail psoriasis, its clinical presentation, diagnostic and assessment methods, clinical repercussions, and of its available treatment options. PMID:24770509
Schons, Karen Regina Rosso; Knob, Cristiane Faccin; Murussi, Nádia; Beber, André Avelino Costa; Neumaier, Walter; Monticielo, Odirlei André
Nails are considered epidermal appendages, and as such, are commonly affected in patients with psoriasis, 80% of whom are likely to develop nail psoriasis as a result of their condition. Two patterns of nail disorders have been shown to be caused by psoriasis. Nail matrix involvement can result in features such as leukonychia, pitting (punctures or cupuliform depressions), red spots in the lunula and crumbling. Nail bed involvement, on the other hand, can cause onycholysis, salmon or oil-drop patches, subungual hyperkeratosis and splinter hemorrhages. Nail disease causes aesthetic and functional impairment, and is indicative of more severe forms of psoriasis as well as of joint involvement. The treatment for nail psoriasis involves behavioral interventions, topical medications, or systemic therapy in case of extensive skin or joint involvement. This article presents a review of the main features of nail psoriasis, its clinical presentation, diagnostic and assessment methods, clinical repercussions, and of its available treatment options.
Baran, R; Schoon, D
For reasons of clarity, definitions are offered for strength, hardness, flexibility, brittleness and toughness of the nails. Six clinical types of nail fragility are delineated: longitudinal furrows and splitting (onychorrhexis), single longitudinal splitting, multiple crenellated splitting, lamellar splitting (onychoschizia), transverse splitting and nail friability. Changes may be observed in the keratin structure of fragile nails. Nail brittleness is usually 'environmental' in origin, but sometimes may be part of a nail dystrophy. Household daily chores are particularly damaging. Among the acquired general causes, hypochromic anaemia and sideropaenia, arthritic deformities of the distal joints, peripheral vascular impairment and endocrinopathies are the best known. Useful therapeutic approaches are updated. They entail protection with plastic gloves worn over light cotton glove linings, the use of nail hardeners composed of two main types of products: a modified nail varnish that functions as a base coat or a hardener, such as dimethyl urea, which overcomes the objections related to formaldehyde; a systemic drug, biotine, is still useful.
Baswan, Sudhir; Kasting, Gerald B; Li, S Kevin; Wickett, Randy; Adams, Brian; Eurich, Sean; Schamper, Ryan
The topical treatment of nail fungal infections has been a focal point of nail research in the past few decades as it offers a much safer and focused alternative to conventional oral therapy. Although the current focus remains on exploring the ways of enhancing permeation through the formidable nail barrier, the understanding of the nail microstructure and composition is far from complete. This article reviews our current understanding of the nail microstructure, composition and diseases. A few of the parameters affecting the nail permeability and potential causes of the recurrence of fungal nail infection are also discussed. © 2017 Blackwell Verlag GmbH.
Westermann, Robert W; DeBerardino, Thomas; Amendola, Annunziato
The High Tibial Osteotomy (HTO) is a reliable procedure in addressing uni- compartmental arthritis with associated coronal deformities. With osteotomy of the proximal tibia, there is a risk of altering the tibial slope in the sagittal plane. Surgical techniques continue to evolve with trends towards procedure reproducibility and simplification. We evaluated a modification of the Arthrex iBalance technique in 18 paired cadaveric knees with the goals of maintaining sagittal slope, increasing procedure efficiency, and decreasing use of intraoperative fluoroscopy. Nine paired cadaveric knees (18 legs) underwent iBalance medial opening wedge high tibial osteotomies. In each pair, the right knee underwent an HTO using the modified technique, while all left knees underwent the traditional technique. Independent observers evaluated postoperative factors including tibial slope, placement of hinge pin, and implant placement. Specimens were then dissected to evaluate for any gross muscle, nerve or vessel injury. Changes to posterior tibial slope were similar using each technique. The change in slope in traditional iBalance technique was -0.3° ±2.3° and change in tibial slope using the modified iBalance technique was -0.4° ±2.3° (p=0.29). Furthermore, we detected no differences in posterior tibial slope between preoperative and postoperative specimens (p=0.74 traditional, p=0.75 modified). No differences in implant placement were detected between traditional and modified techniques. (p=0.85). No intraoperative iatrogenic complications (i.e. lateral cortex fracture, blood vessel or nerve injury) were observed in either group after gross dissection. Alterations in posterior tibial slope are associated with HTOs. Both traditional and modified iBalance techniques appear reliable in coronal plane corrections without changing posterior tibial slope. The present modification of the Arthrex iBalance technique may increase the efficiency of the operation and decrease radiation
Westermann, Robert W; DeBerardino, Thomas; Amendola, Annunziato
Introduction The High Tibial Osteotomy (HTO) is a reliable procedure in addressing uni- compartmental arthritis with associated coronal deformities. With osteotomy of the proximal tibia, there is a risk of altering the tibial slope in the sagittal plane. Surgical techniques continue to evolve with trends towards procedure reproducibility and simplification. We evaluated a modification of the Arthrex iBalance technique in 18 paired cadaveric knees with the goals of maintaining sagittal slope, increasing procedure efficiency, and decreasing use of intraoperative fluoroscopy. Methods Nine paired cadaveric knees (18 legs) underwent iBalance medial opening wedge high tibial osteotomies. In each pair, the right knee underwent an HTO using the modified technique, while all left knees underwent the traditional technique. Independent observers evaluated postoperative factors including tibial slope, placement of hinge pin, and implant placement. Specimens were then dissected to evaluate for any gross muscle, nerve or vessel injury. Results Changes to posterior tibial slope were similar using each technique. The change in slope in traditional iBalance technique was -0.3° ±2.3° and change in tibial slope using the modified iBalance technique was -0.4° ±2.3° (p=0.29). Furthermore, we detected no differences in posterior tibial slope between preoperative and postoperative specimens (p=0.74 traditional, p=0.75 modified). No differences in implant placement were detected between traditional and modified techniques. (p=0.85). No intraoperative iatrogenic complications (i.e. lateral cortex fracture, blood vessel or nerve injury) were observed in either group after gross dissection. Discussion & Conclusions Alterations in posterior tibial slope are associated with HTOs. Both traditional and modified iBalance techniques appear reliable in coronal plane corrections without changing posterior tibial slope. The present modification of the Arthrex iBalance technique may increase the
Sessa, Pasquale; Fioravanti, Giulio; Giannicola, Giuseppe; Cinotti, Gianluca
In cruciate retaining total knee arthroplasty (TKA), a partial avulsion of PCL may occur when en-bloc tibial osteotomy is performed. We evaluated the effects of a tibial cut performed with different degrees of posterior slope on PCL insertion and whether the results are affected by the sagittal inclination of the patient's tibial plateau. We selected 83 MRIs of knees showing mild or no degenerative changes. The effects of a simulated tibial cut performed with a posterior slope of 0°, 3°, 5° and parallel to the patient's tibial plateau inclination on PCL insertion in the proximal tibia were investigated. The results were correlated with the degree of posterior inclination of the tibial plateau. Every angle we used for the tibial cut caused a PCL avulsion greater than 50%. The percentage of PCL avulsion significantly increased with increasing the posterior slope of the tibial cut. Patients with sagittal tibial plateau inclination <5° showed greater PCL avulsion than those with sagittal inclination >8°. Most of the PCL insertion is likely to be sacrificed when resection of the proximal tibia is performed en-block. The risk of PCL avulsion is reduced in patients showing a marked posterior inclination of the tibial plateau, but even in this group of patients a surgical technique aimed at sparing most of the PCL insertion is necessary. Copyright © 2014 Elsevier B.V. All rights reserved.
Parker, M J; Handoll, H H
Cephalocondylic intramedullary nails which are inserted proximally to distally (cephalocondylic) have been used for the surgical treatment of extracapsular hip fractures. To compare all cephalocondylic intramedullary nails with extramedullary implants for the surgical treatment of extracapsular hip fractures in adults. This is the third substantive update of our original review which compared the Gamma nail with the sliding hip screw (SHS). We searched the Cochrane Musculoskeletal Injuries Group trials register, MEDLINE, select orthopaedic journals and conference proceedings, and reference lists of relevant articles. We contacted trialists, colleagues and implant manufacturers. Date of the most recent search: August 2002. All randomised and quasi-randomised trials comparing cephalocondylic nails with extramedullary implants for extracapsular hip fractures. Both reviewers independently assessed trial quality and extracted data. Additional information was sought from all trialists. Wherever appropriate and possible, results were pooled. Seventeen trials comparing the Gamma nail with the SHS were included, with data available for 2472 patients. The Gamma nail was associated with an increased risk of operative and later fracture of the femur and an increased re-operation rate. There were no major differences in the incidence of wound infection, mortality or medical complications between implants. Data were inadequate for other outcomes. Five trials involving 623 patients compared the intramedullary hip screw (IMHS) with the SHS. Fracture fixation complications were more common in the IMHS group: all cases of operative and later fracture of the femur occurred in this group. Results for post-operative complications, mortality and functional outcomes were similar in the two groups. One study of 206 patients with a trochanteric fracture showed no advantages for proximal femoral nail (PFN) compared with the SHS. One trial of 60 patients reported favourable preliminary
Topal, Ilteris Oguz; Gungor, Sule; Kocaturk, Ozgur Emek; Duman, Hatice; Durmuscan, Mustafa
Vitiligo is an acquired pigmentary skin disorder affecting 0.1-4% of the general population. The nails may be affected in patients with an autoimmune disease such as psoriasis, and in those with alopecia areata. It has been suggested that nail abnormalities should be apparent in vitiligo patients. We sought to document the frequency and clinical presentation of nail abnormalities in vitiligo patients compared to healthy volunteers. We also examined the correlations between nail abnormalities and various clinical parameters. This study included 100 vitiligo patients and 100 healthy subjects. Full medical histories were collected from the subjects, who underwent thorough general and nail examinations. All nail changes were noted. In the event of clinical suspicion of a fungal infection, additional mycological investigations were performed. Nail abnormalities were more prevalent in the patients (78%) than in the controls (55%) (p=0.001). Longitudinal ridging was the most common finding (42%), followed by (in descending order): leukonychia, an absent lunula, onycholysis, nail bed pallor, onychomycosis, splinter hemorrhage and nail plate thinning. The frequency of longitudinal ridging was significantly higher in patients than in controls (p<0.001). Nail abnormalities were more prevalent in vitiligo patients than in controls. Systematic examination of the nails in such patients is useful because nail abnormalities are frequent. However, the causes of such abnormalities require further study. Longitudinal ridging and leukonychia were the most common abnormalities observed in this study.
Topal, Ilteris Oguz; Gungor, Sule; Kocaturk, Ozgur Emek; Duman, Hatice; Durmuscan, Mustafa
Background Vitiligo is an acquired pigmentary skin disorder affecting 0.1-4% of the general population. The nails may be affected in patients with an autoimmune disease such as psoriasis, and in those with alopecia areata. It has been suggested that nail abnormalities should be apparent in vitiligo patients. Objective We sought to document the frequency and clinical presentation of nail abnormalities in vitiligo patients compared to healthy volunteers. We also examined the correlations between nail abnormalities and various clinical parameters. Methods This study included 100 vitiligo patients and 100 healthy subjects. Full medical histories were collected from the subjects, who underwent thorough general and nail examinations. All nail changes were noted. In the event of clinical suspicion of a fungal infection, additional mycological investigations were performed. Results Nail abnormalities were more prevalent in the patients (78%) than in the controls (55%) (p=0.001). Longitudinal ridging was the most common finding (42%), followed by (in descending order): leukonychia, an absent lunula, onycholysis, nail bed pallor, onychomycosis, splinter hemorrhage and nail plate thinning. The frequency of longitudinal ridging was significantly higher in patients than in controls (p<0.001). Conclusions Nail abnormalities were more prevalent in vitiligo patients than in controls. Systematic examination of the nails in such patients is useful because nail abnormalities are frequent. However, the causes of such abnormalities require further study. Longitudinal ridging and leukonychia were the most common abnormalities observed in this study. PMID:27579738
Argintar, Evan; Cohen, Mark; Eglseder, Andrew; Edwards, Scott
Proximal ulnar fractures have traditionally been fixed with either tension band wiring or plate and screw fixation. These traditional techniques often irritate the surrounding soft tissues, potentially leading to subsequent secondary hardware removal surgeries. Intramedullary proximal ulnar fixation provides similar rigid fixation, however, no review yet exists to support the clinical use of currently available implants. To investigate the clinical and radiographic short-term outcomes for multiplanar locked intramedullary nails used to treat proximal ulnar fractures. A retrospective multicenter review was conducted in 28 patients with unstable olecranon fractures treated with a new multiplanar locked intramedullary nailing system (OlecraNail, Mylad Orthopedic Solutions, McLean, VA). Radiographic union was estimated, and serial clinical outcome up to one year was assessed by strength, motion, pain (visual analog scale), and a subcutaneous ulna border palpation (SCUBP) test to assess hardware prominence. All fractures achieved union by 8 weeks. At 12 weeks postoperatively, all motion was within 10 degrees of the contralateral side in all directions. Of the 18 patients who underwent SCUBP testing, all 18 patients reported to have no pain at 12 weeks. At one-year follow-up, all patients had resumed normal activities, including work and athletics. All of the patients who underwent the SCUBP testing continued to have no pain. Multiplanar locked intramedullary nails offer effective management for proximal ulna fractures similar to those reported with plating techniques. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
Xavier, F; Goldwyn, E; Hayes, W; Carrer, A; Elkhechen, R; Berdichevsky, M; Goldman, A; Urban, W; Saha, S
Treatment of distal metaphyseal tibia fractures is often challenging. Newer tibial intramedullary (IM) nails are designed with a wider variety of distal locking options to offer greater stability in treating these fractures. In this study we attempted to determine the most biomechanically stable number and configuration of distal locking screws when treating distal metaphyseal tibia fractures with IM nails. A transverse osteotomy was created 4 cm from the tibial plafond in identical composite saw bones models (Type 43A fracture) as well as in human cadaveric bones. Each specimen was nailed using a tibial nail (Stryker T2). Distal locking was performed in one of the three configurations: (a) Group I: two screws in the medial lateral (ML) direction; (b) Group II: one ML screw and one screw in the anterior posterior (AP) direction; (c) Group 111: two ML screws and one AP screw. The specimens were then mounted onto a uniaxial material testing machine (Instron) and tested in compression. Our results showed that there was no statistical difference in the load-carrying capacity of Group 1 and Group II. This suggests that the treating surgeon can choose either of these two configurations depending on the wound or other considerations without sacrificing the compressive load-carrying capacity of the IM nail fixation. The load-carrying capacity of the Group III samples with these locking screws was higher than those of Group I & II, although this difference was not statistically significant. This work is being continued to compare the load-carrying capacity of the bone samples with the cortical thickness of bone. We also plan to examine the relationship between the load-carrying capacity of these surgical constructs with the bone mineral density of the metaphysis of these tibial specimens.
Amerinatanzi, Amirhesam; Summers, Rodney K.; Ahmadi, Kaveh; Goel, Vijay K.; Hewett, Timothy E.; Nyman, Edward
Background: Multi-planar proximal tibial slopes may be associated with increased likelihood of osteoarthritis and anterior cruciate ligament injury, due in part to their role in checking the anterior-posterior stability of the knee. Established methods suffer repeatability limitations and lack computational efficiency for intuitive clinical adoption. The aims of this study were to develop a novel automated approach and to compare the repeatability and computational efficiency of the approach against previously established methods. Methods: Tibial slope geometries were obtained via MRI and measured using an automated Matlab-based approach. Data were compared for repeatability and evaluated for computational efficiency. Results: Mean lateral tibial slope (LTS) for females (7.2°) was greater than for males (1.66°). Mean LTS in the lateral concavity zone was greater for females (7.8° for females, 4.2° for males). Mean medial tibial slope (MTS) for females was greater (9.3° vs. 4.6°). Along the medial concavity zone, female subjects demonstrated greater MTS. Conclusion: The automated method was more repeatable and computationally efficient than previously identified methods and may aid in the clinical assessment of knee injury risk, inform surgical planning, and implant design efforts. PMID:28952547
Reinig, Erica; Rich, Phoebe; Thompson, Curtis T
The scarcity of specific submission protocols for nail unit biopsies presents many challenges for appropriate specimen processing. Many nail biopsies are received fragmented or without orientation, often resulting in less-than-ideal tissue embedding and poor histologic sections, which are difficult to interpret. Methods are described for proper nail matrix/bed biopsy and plate submission that incorporate aspects of previous submission protocols and include inking the biopsy specimen along with submitting the tissue on a drawing of the nail. Also described is a technique for maintaining adherence of nail plate to glass slides, a chronic challenge in the laboratory.
Chiacchio, Nilton Di; de Farias, Débora Cadore; Piraccini, Bianca Maria; Hirata, Sergio Henrique; Richert, Bertrand; Zaiac, Martin; Daniel, Ralph; Fanti, Pier Alessandro; Andre, Josette; Ruben, Beth S; Fleckman, Philip; Rich, Phoebe; Haneke, Eckart; Chang, Patricia; Cherit, Judith Dominguez; Scher, Richard; Tosti, Antonella
This statement, focused on melanonychia and nail plate dermoscopy, is intended to guide medical professionals working with melanonychia and to assist choosing appropriate management for melanonychia patients. The International Study Group on Melanonychia was founded in 2007 and currently has 30 members, including nail experts and dermatopathologists with special expertise in nails. The need for common definitions of nail plate dermoscopy was addressed during the Second Meeting of this Group held in February 2008. Prior to this meeting and to date (2010) there have been no evidence-based guidelines on the use of dermoscopy in the management of nail pigmentation. PMID:23739699
Durnova, G N; Kaplanskii, A S; Morey-Holton, E R; Vorobéva, V N
Proximal metaphyses of tibial bones from the Sprague-Dowly rats exposed in US dedicated space life sciences laboratory SLS-2 for 13-14 days and sacrificed on day 13 in microgravity and within 5 hours and 14 days following recovery were the subject of histological, histochemical, and histomorphometric analyses. After the 13-day flight of SLS-2 the rats showed initial signs of osteopenia in the spongy tissue of tibial bones, secondary spongiosis affected first. Resorption of the secondary spongiosis was consequent to enhanced resorption and inhibition of osteogenesis. In rats sacrificed within 5 hours of recovery manifestations of tibial osteopenia were more evident than in rats sacrificed during the flight. Spaceflight-induced changes in tibial spongiosis were reverse by character the amount of spongy bone was fully compensated and following 14 days of readaptation to the terrestrial gravity.
Durnova, G. N.; Kaplanskii, A. S.; Morey-Holton, E. R.; Vorobeva, V. N.
Proximal metaphyses of tibial bones from the Sprague-Dowly rats exposed in US dedicated space life sciences laboratory SLS-2 for 13-14 days and sacrificed on day 13 in microgravity and within 5 hours and 14 days following recovery were the subject of histological, histochemical, and histomorphometric analyses. After the 13-day flight of SLS-2 the rats showed initial signs of osteopenia in the spongy tissue of tibial bones, secondary spongiosis affected first. Resorption of the secondary spongiosis was consequent to enhanced resorption and inhibition of osteogenesis. In rats sacrificed within 5 hours of recovery manifestations of tibial osteopenia were more evident than in rats sacrificed during the flight. Spaceflight-induced changes in tibial spongiosis were reverse by character the amount of spongy bone was fully compensated and following 14 days of readaptation to the terrestrial gravity.
Torres, André Leal Gonçalves; Ferreira, Marcus Castro
Objective Determine, through dissection in fresh cadavers, the topographic anatomy of the tibial nerve and its branches at the ankle, in relation to the tarsal tunnel. Methods Bilateral dissections were performed on 26 fresh cadavers and the locations of the tibial nerve bifurcation and its branches were measured in millimeters. For the calcaneal branches, the amount and their respective nerves of origin were also analyzed. Results The tibial nerve bifurcation occurred under the tunnel in 88% of the cases and proximally in 12%. As for the calcaneal branches, the medial presented with one (58%), two (34%) and three (8%) branches, with the most common source occurring in the tibial nerve (90%) and the lower with a single branch per leg and lateral plantar nerve as the most common origin (70%). Level of Evidence, V Expert opinion. PMID:24453596
Huang, Zhong-lian; Yang, Hai-long; Xu, Jian-kun; Xia, Xue; Wang, Xin-jia; Song, Jian-xin; Hu, Jun
Intramedullary nails had been widely used in the treatment of long-bone fractures because of less interference of fractures and center bearing biomechanical advantage. However, it had been also found many shortcomings such as broken nails, delayed healing and was modified in order to achieve better efficacy and reduce complications. The aim of the present study is to compare the efficacy of rotary self-locking intramedullary nails (RSIN) with that of interlocking intramedullary nails (IIN) in the treatment of long-bone fractures. A retrospective study investigated 129 cases with long-bone fractures (36 with femoral fracture, 81 with tibial fracture, and 12 with humeral fracture). The fractures were fixed using either an RSIN or IIN. All patients underwent followup for 12-30 months. All patients in both groups achieved a clinical fracture healing standard and the postoperative affected limb muscle strength and joint function were well restored. The RSIN group required a shorter operative time and the fracture healed faster. There was no significant difference in the hospital stay, intraoperative blood loss or postoperative complications between the two groups. RSIN is used to treat long-bone fractures. Its healing efficacy is equivalent to the IIN. Moreover, the RSIN method is simpler and causes less tissue damage than the IIN, therefore having the advantage of accelerated healing.
Parker, M J; Handoll, H H
Cephalocondylic intramedullary nails which are inserted proximally to distally (cephalocondylic) have been used for the surgical treatment of extracapsular hip fractures. To compare all cephalocondylic intramedullary nails with extramedullary implants for the surgical treatment of extracapsular hip fractures in adults. This is the third update of our original review which compared the Gamma nail with the sliding hip screw (SHS). We searched the Cochrane Musculoskeletal Injuries Group trials register, MEDLINE, select orthopaedic journals and conference proceedings, and reference lists of relevant articles. We contacted trialists, colleagues and implant manufacturers. Date of the most recent search: August 2001. All randomised and quasi-randomised trials comparing cephalocondylic nails with extramedullary implants for extracapsular hip fractures. Both reviewers independently assessed trial quality and extracted data. Additional information was sought from all trialists. Wherever appropriate and possible, results were pooled. The one trial of 230 patients comparing the Kuntscher-Y nail with the SHS, reported no major difference the outcome aside from a significantly increased number of patients with leg shortening, and a tendency for poorer recovery of mobility in the Kuntscher-Y nail group. Seventeen trials comparing the Gamma nail with the SHS were included, with data available for 2472 patients. The Gamma nail was associated with an increased risk of operative and later fracture of the femur and an increased re-operation rate. There were no major differences in the incidence of wound infection, mortality or medical complications between implants. Data were inadequate to determine if there were differences for other outcomes. Five trials involving 603 patients compared the intramedullary hip screw (IMHS) with the SHS. Fracture fixation complications were more common in the IMHS group: all cases of operative and later fracture of the femur occurred in this group
Reshef, Noam; Guelich, David R
MTSS is a benign, though painful, condition, and a common problem in the running athlete. It is prevalent among military personnel, runners, and dancers, showing an incidence of 4% to 35%. Common names for this problem include shin splints, soleus syndrome, tibial stress syndrome, and periostitis. The exact cause of this condition is unknown. Previous theories included an inflammatory response of the periosteum or periosteal traction reaction. More recent evidence suggests a painful stress reaction of bone. The most proven risk factors are hyperpronation of the foot, female sex, and history of previous MTSS. Patient evaluation is based on meticulous history taking and physical examination. Even though the diagnosis remains clinical, imaging studies, such as plain radiographs and bone scans are usually sufficient, although MRI is useful in borderline cases to rule out more significant pathology. Conservative treatment is almost always successful and includes several options; though none has proven more superior to rest. Prevention programs do not seem to influence the rate of MTSS, though shock-absorbing insoles have reduced MTSS rates in military personnel, and ESWT has shortened the duration of symptoms. Surgery is rarely indicated but has shown some promising results in patients who have not responded to all conservative options.
Lucas-Cuevas, Angel Gabriel; Encarnación-Martínez, Alberto; Camacho-García, Andrés; Llana-Belloch, Salvador; Pérez-Soriano, Pedro
Tibial accelerations have been associated with a number of running injuries. However, studies attaching the tibial accelerometer on the proximal section are as numerous as those attaching the accelerometer on the distal section. This study aimed to investigate whether accelerometer location influences acceleration parameters commonly reported in running literature. To fulfil this purpose, 30 athletes ran at 2.22, 2.78 and 3.33 m · s(-1) with three accelerometers attached with double-sided tape and tightened to the participants' tolerance on the forehead, the proximal section of the tibia and the distal section of the tibia. Time-domain (peak acceleration, shock attenuation) and frequency-domain parameters (peak frequency, peak power, signal magnitude and shock attenuation in both the low and high frequency ranges) were calculated for each of the tibial locations. The distal accelerometer registered greater tibial acceleration peak and shock attenuation compared to the proximal accelerometer. With respect to the frequency-domain analysis, the distal accelerometer provided greater values of all the low-frequency parameters, whereas no difference was observed for the high-frequency parameters. These findings suggest that the location of the tibial accelerometer does influence the acceleration signal parameters, and thus, researchers should carefully consider the location they choose to place the accelerometer so that equivalent comparisons across studies can be made.
Dogra, Alka; Arora, Amanjot Kaur
Nail involvement is an extremely common feature of psoriasis and affects approximately 10-78% of psoriasis patients with 5-10% of patients having isolated nail psoriasis. However, it is often an overlooked feature in the management of nail psoriasis, despite the significant burden it places on the patients as a result of functional impairment of manual dexterity, pain, and psychological stress. Affected nail plates often thicken and crumble, and because they are very visible, patients tend to avoid normal day-to-day activities and social interactions. Importantly, 70-80% of patients with psoriatic arthritis have nail psoriasis. In this overview, we review the clinical manifestations of psoriasis affecting the nails, the common differential diagnosis of nail psoriasis, Nail Psoriasis Severity Index and the various diagnostic aids for diagnosing nail psoriasis especially, the cases with isolated nail involvement. We have also discussed the available treatment options, including the topical, physical, systemic, and biological modalities, in great detail in order to equip the present day dermatologist in dealing with a big clinical challenge, that is, management of nail psoriasis. PMID:25071247
Delgado-Charro, Maria Begoña
Topical drug delivery to treat nail diseases such as onychomycosis and psoriasis is receiving increasing attention. Topical nail delivery is challenged by the complicated structure of the nail and the low permeability of most drugs across the nail plate. Considerable effort has been directed at developing methods to promote drug permeation across the nail plate. Iontophoresis efficiently enhances molecular transport across the skin and the eye and is now being tested for its potential in ungual delivery. This review covers the basic mechanisms of transport (electro-osmosis and -migration) and their relative contribution to nail iontophoresis as well as the key factors governing nail permselectivity and ionic transport numbers. Methodological issues concerning research in this area are summarized. The data available in vivo on nail iontophoresis of terbinafine specifically are reviewed in separate sections. Our understanding of nail iontophoresis has improved considerably since 2007; most decisively, the feasibility of nail iontophoresis in vivo has been clearly demonstrated. Future work is required to establish the adequate implementation of the technique so that its clinical efficacy to treat onychomycosis and nail psoriasis can be unequivocally determined.
For those interested in nails, a fairly good knowledge of the anatomy of the nail unit is indispensable. But nothing will replace a careful, clinical examination of the nail apparatus. The shape of the nail, surface abnormalities and coloration, with or without a magnifying glass, may well provide a medical diagnosis not only in dermatology but also for medicine in general. Pits on the surface of the nail plate may be enough to diagnose psoriasis on a limited area of scalp dandruff. Even partial detachment of the nail apparatus might lead to the suspicion of psoriatic arthritis. A triangular lunula is associated with the absence of patellas. Finally, no pulmonary examination of a smoker is complete without looking for clubbing. It is high time to pay tribute to the nail.
Gali, Julio Cesar; Esquerdo, Paulo; Almagro, Marco Antonio Pires; da Silva, Phelipe Augusto Cintra
Objective To establish the radiographic distances from posterior cruciate ligament (PCL) tibial insertions centers to the lateral and medial tibial cortex in the anteroposterior view, and from these centers to the PCL facet most proximal point on the lateral view, in order to guide anatomical tunnels drilling in PCL reconstruction and for tunnel positioning postoperative analysis. Study design Controlled laboratory study. Methods Twenty cadaver knees were evaluated. The PCL's bundles tibial insertions were identified and marked out using metal tags, and the knees were radiographed. On these radiographs, the bundles insertion sites center location relative to the tibial mediolateral measure, and the distances from the most proximal PCL facet point to the bundle's insertion were determined. All measures were calculated using the ImageJ software. Results On the anteroposterior radiographs, the mean distance from the anterolateral (AL) bundle insertion center to the medial tibial edge was 40.68 ± 4.10 mm; the mean distance from the posteromedial (PM) bundle insertion center to the medial tibial edge was 38.74 ± 4.40 mm. On the lateral radiographs, the mean distances from the PCL facet most proximal point to AL and PM bundles insertion centers were 5.49 ± 1.29 mm and 10.53 ± 2.17 mm respectively. Conclusions It was possible to establish a radiographic pattern for PCL tibial bundles insertions, which may be useful for intraoperative tunnels locations control and for postoperative tunnels positions analysis. PMID:26229941
Lacey, Matthew; Lamplot, Joseph; Walley, Kempland C; DeAngelis, Joseph P; Ramappa, Arun J
stitched, quadrupled and shaped to match the diameter of the prepared femoral tunnel. If the diameter of the patient's autologous hamstring graft is insufficient to fill the prepared femoral tunnel, the autograft may be supplemented with an allograft. The remainder of the reconstruction is performed according to surgeon preference. The presence of retained hardware presents a challenge for surgeons treating patients with knee instability. In cruciate ligament reconstruction, distal femoral and proximal tibial implants hardware may confound tunnel placement, making removal of hardware necessary, unless techniques are adopted to allow for anatomic placement of the graft. This report demonstrates how the femoral tunnel can be created using the anteromedial portal instead of a transtibial approach for reconstruction of the ACL.
Lacey, Matthew; Lamplot, Joseph; Walley, Kempland C; DeAngelis, Joseph P; Ramappa, Arun J
tendons are whip stitched, quadrupled and shaped to match the diameter of the prepared femoral tunnel. If the diameter of the patient’s autologous hamstring graft is insufficient to fill the prepared femoral tunnel, the autograft may be supplemented with an allograft. The remainder of the reconstruction is performed according to surgeon preference. RESULTS The presence of retained hardware presents a challenge for surgeons treating patients with knee instability. In cruciate ligament reconstruction, distal femoral and proximal tibial implants hardware may confound tunnel placement, making removal of hardware necessary, unless techniques are adopted to allow for anatomic placement of the graft. CONCLUSION This report demonstrates how the femoral tunnel can be created using the anteromedial portal instead of a transtibial approach for reconstruction of the ACL. PMID:28567341
Shen, Yi; Li, Xiaomiao; Fu, Xiaodong; Wang, Weili
Posterior tibial slope that is created during proximal tibial resection in total knee arthroplasty has emerged as an important factor in the mechanics of the knee joint and the surgical outcome. But the ideal degree of posterior tibial slope for recovery of the knee joint function and preventions of complications remains controversial and should vary in different racial groups. The objective of this paper is to investigate the effects of posterior tibial slope on contact stresses in the tibial polyethylene component of total knee prostheses. Three-dimensional finite element analysis was used to calculate contact stresses in tibial polyethylene component of total knee prostheses subjected to a compressive load. The 3D finite element model of total knee prosthesis was constructed from the images produced by 3D scanning technology. Stresses in tibial polyethylene component were calculated with four different posterior tibial slopes (0°, 3°, 6° and 9°). The 3D finite element model of total knee prosthesis we presented was well validated. We found that the stress distribution in the polythene as evaluated by the distributions of the von Mises stress, the maximum principle stress, the minimum principle stress and the Cpress were more uniform with 3° and 6° posterior tibial slopes than with 0° and 9° posterior tibial slopes. Moreover, the peaks of the above stresses and trends of changes with increasing degree of knee flexion were more ideal with 3° and 6° posterior slopes. The results suggested that the tibial component inclination might be favourable to 7°-10° so far as the stress distribution is concerned. The range of the tibial component inclination also can decrease the wear of polyethylene. Chinese posterior tibial slope is bigger than in the West, and the current domestic use of prostheses is imported from the West, so their demands to tilt back bone cutting can lead to shorten the service life of prostheses; this experiment result is of important
Jacobi, Matthias; Villa, Vincent; Reischl, Nikolaus; Demey, Guillaume; Goy, Damien; Neyret, Philippe; Gautier, Emanuel; Magnussen, Robert A
Opening wedge high tibial osteotomy (HTO) is an accepted treatment option for medial compartment knee osteoarthritis with associated varus lower limb axis in younger, more active patients. A concern with the use of this technique is that posterior tibial slope (PTS) and tibial rotation can be altered. We hypothesized that there is a tendency to increase the PTS and internal rotation of the distal tibia during the procedure and that certain intra-operative parameters may influence the amount of change that can be expected. A cadaveric model and surgical navigation system were used to evaluate the influence of certain intra-operative factors of the degree of PTS and tibial rotation change observed during medial opening HTO. Parameters evaluated included: degree of osteotomy opening, knee flexion angle, location of limb support (thigh versus foot), performance of a posteromedial release, the status of the lateral cortical hinge, and the degree of osteoarthritis present in the knee. Combining measurements of all specimens and parameters, a mean PTS increase of 2.7° ± 3.9° and a mean tibial internal rotation of 1.5° ± 2.9° were observed. Clinically, significant changes in tibial slope (>2°) occurred in 50.4 % of corrections, while significant changes in tibial rotation (>5°) occurred in only 11.9 % of corrections. Patients with significant osteoarthritis and concomitant flexion contracture, cases where large corrections were required, and procedures in which the lateral cortical hinge was disrupted were associated with increased PTS change. The other factors evaluated did not exert a significant influence of the degree of PTS change observed. Surgeons should be vigilant for possible PTS change, particularly in high-risk situations as outlined above. Routine use of an intra-operative measure of PTS is recommended to avoid inadvertent slope change.
Zbeda, Robert M; Sculco, Peter K; Urch, Ekaterina Y; Lazaro, Lionel E; Borens, Olivier; Williams, Riley J; Lorich, Dean G; Wellman, David S; Helfet, David L
Anterior tibial stress fractures are associated with high rates of delayed union and nonunion, which can be particularly devastating to a professional athlete who requires rapid return to competition. Current surgical treatment strategies include intramedullary nailing, which has satisfactory rates of fracture union but an associated risk of anterior knee pain. Anterior tension band plating is a biomechanically sound alternative treatment for these fractures. Tension band plating of chronic anterior tibial stress fractures leads to rapid healing and return to physical activity and avoids the anterior knee pain associated with intramedullary nailing. Case series; Level of evidence, 4. Between 2001 and 2013, there were 13 chronic anterior tibial stress fractures in 12 professional or collegiate athletes who underwent tension band plating after failing nonoperative management. Patient charts were retrospectively reviewed for demographics, injury history, and surgical details. Radiographs were used to assess time to osseous union. Follow-up notes and phone interviews were used to determine follow-up time, return to training time, and whether the patient was able to return to competition. Cases included 13 stress fractures in 12 patients (9 females, 3 males). Five patients were track-and-field athletes, 4 patients played basketball, 2 patients played volleyball, and 1 was a ballet dancer. Five patients were Division I collegiate athletes and 7 were professional or Olympic athletes. Average age at time of surgery was 23.6 years (range, 20-32 years). Osseous union occurred on average at 9.6 weeks (range, 5.3-16.9 weeks) after surgery. Patients returned to training on average at 11.1 weeks (range, 5.7-20 weeks). Ninety-two percent (12/13) eventually returned to preinjury competition levels. Thirty-eight percent (5/13) underwent removal of hardware for plate prominence. There was no incidence of infection or nonunion. Anterior tension band plating for chronic tibial stress
LOIA, MARCO CORGIAT; VANNI, STEFANIA; ROSSO, FEDERICA; BONASIA, DAVIDE EDOARDO; BRUZZONE, MATTEO; DETTONI, FEDERICO; ROSSI, ROBERTO
Opening wedge high tibial osteotomy (OWHTO) is a surgical procedure that aims to correct the weight-bearing axis of the knee, moving the loads laterally from the medial compartment. Conventional indications for OWHTO are medial compartment osteoarthritis and varus malalignment of the knee; recently OWHTO has been used successfully in the treatment of double and triple varus. OWHTO, in contrast to closing wedge high tibial osteotomy, does not require fibular osteotomy or peroneal nerve dissection, or lead to disruption of the proximal tibiofibular joint and bone stock loss. For these reasons, interest in this procedure has grown in recent years. The aim of this study is to review the literature on OWHTO, considering indications and prognostic factors (body mass index, grade of osteoarthritis, instability, range of movement and age), outcomes at mid-term follow-up, and limits of the procedure (slope modifications, patellar height changes and difficulties in conversion to a total knee arthroplasty). PMID:27602350
Vaidya, Sandeep V; Song, Hae-Ryong; Lee, Seok-Hyun; Suh, Seung-Woo; Keny, Swapnil M; Telang, Shailendra S
The results and complications of bifocal tibial osteotomies with gradual correction and lengthening by Ilizarov ring fixator performed in 47 tibiae in 24 achondroplastic patients were analyzed. Comparison was made between the parameters of angular and torsional deformities of the tibia preoperatively, at fixator removal, and at last follow-up. Of these parameters, statistically significant change was seen postoperatively in the values of medial proximal tibial angle, lateral distal tibial angle, mechanical axis deviation, and tibial torsion, which changed from 78.8 +/- 7.05 degrees, 103.2 +/- 11.8 degrees, 25.1 +/- 14.6 mm (medial), and 22.7 +/- 10 degrees (internal) preoperatively to 87.3 +/- 6.3 degrees, 90.9 +/- 5.4 degrees, 5.3 +/- 10 cm (medial), and 15.8 +/- 4.2 degrees (external), respectively, at the time of fixator removal; and this correction was maintained during the follow-up period. Mean total tibial lengthening was 6.84 +/- 1.3 cm. Average healing index was 26.06 days/cm. Complications observed were 15 pin tract infections, 1 residual varus, 1 overcorrection into valgus, 2 recurrence of varus, 22 equinus contractures, 2 premature consolidations, and 3 fibula malalignments. Recurrence of varus was observed in limbs with a residual abnormal medial mechanical axis deviation due to femoral deformity. A hundred percent incidence of equinus was observed in limbs with tibial lengthening of more than 40%, with distal tibial lengthening of more than 15%. To minimize the risk for occurrence of equinus, we recommend restriction of distal tibial lengthening in achondroplasia to less than 15%, although total tibial lengthening may exceed 40%. Fibula malalignment was not observed after double fibula osteotomy. This procedure is safe and efficacious if performed with strict adherence to prescribed technique.
Piraccini, Bianca Maria; Iorizzo, Matilde
Several drugs may be responsible for the development of nail abnormalities, but only a few classes are consistently associated with nail symptoms. Drug-induced nail abnormalities result from toxicity to the matrix, the nail bed, the periungual tissues, or the digit blood vessels. Pharmacologic agents that most frequently produce nail abnormalities include retinoids, indinavir, and cancer chemotherapeutic agents.
Carret, J P; Van Cuyck, A; Bejui, J; Dejour, H; de Mourgues, G; Fischer, L P
After trochanteric fractures, the rate of survival of old patients was best when treated by the Ender method: 15% died during 3 months following the fracture. The procedure is uneasy and an excellent radiologic technique is necessary. The position of the proximal end of the first nail in the femoral head is most important. Excessive external rotation was frequent, but little desabling. Secondary displacement of the nails toward the distal end occurred in 25% of the cases and was difficult to avoid but remained moderate. The procedure is indicated in old people with porotic bones. It should not be done in subtrochanteric fractures.
Hohmann, Erik; Bryant, Adam L; Livingstone, Elisabeth; Reaburn, Peter; Tetsworth, Kevin; Imhoff, Andreas
Fluctuating levels of endogenous estrogen are thought to have an adverse effect on lower limb biomechanics, given the observed higher rate of ACL injury at certain phases of the menstrual cycle. The purpose of this study was to investigate the effects of fluctuating endogenous estrogen levels during the menstrual cycle on acceleration transients at the proximal tibia in young physically active females. Eleven females aged 16-18 years participated in this study and were compared to a male control group. Female subjects were tested at each of the four phases of the menstrual cycle: menses, follicular, ovulation and luteal. On each test occasion, acceleration transients at the proximal tibia were measured while subjects performed an abrupt deceleration task (simulated netball landing). No significant differences were found between the different phases of the menstrual cycle for peak tibial acceleration (PTA; P = 0.57), and time to zero tibial acceleration (TZTA; P = 0.59). However, there was a significant difference for time to peak tibial acceleration (TPTA) between menstruation and follicular (P = 0.04), menstruation and ovulation (P = 0.001), menstruation and luteal phase (P = 0.002), and follicular phase and ovulation (P = 0.007). In the male control group, no significant between-test session differences were observed for PTA (P = 0.48), TZTA (P = 0.08) and TPTA (P = 0.29). While there were no significant between-group differences for PTA (P = 0.21) and TZTA (P = 0.48), significant between-group differences were observed for TPTA (P = 0.001). The results of this project strongly suggest that serum estrogen fluctuations have an effect on tibial acceleration profiles in young female athletes during different phases of the menstrual cycle.
Lee, Dong-Youn; Yang, Jun-Mo; Mun, Goo-Hyun; Jang, Kee-Taek; Cho, Kwang-Hyun
In the frozen longitudinal section of the nail unit, CD10 was previously found in nail mesenchymal cells beneath nail matrix, and we proposed calling the nail mesenchymal cells onychofibroblasts. In this study, to further characterize nail mesenchyme containing onychofibroblasts, we examined the expression of several mesenchymal markers immunohistochemically in transverse paraffin sections of the nail unit. CD10 was strongly expressed in the nail mesenchyme containing onychofibroblasts beneath the nail matrix. However, CD10 was not observed in dermal fibroblasts and surrounding extracellular matrix of the lateral nail fold (LNF), except around blood vessels and eccrine structures. In addition, versican was expressed diffusely in the nail mesenchyme containing onychofibroblasts in contrast to the dermis of LNF. Fibrillin, which is a major component of elastic fiber in the dermis, was expressed very weakly on the nail mesenchyme below the nail matrix but was expressed strongly in the dermis of LNF. These findings support the existence of specialized nail mesenchyme containing onychofibroblasts that is distinguished from the dermis of LNF.
Tibial dyschondroplasia (TD), a major metabolic cartilage disease in poultry, is characterized by the distension of proximal growth plates of tibia which fail to form bone, lack blood vessels, and contain nonviable cells. Thiram, a carbamate pesticide, when fed to young broiler chicks induces TD wi...
Bisicchia, Salvatore; Scordo, Gavinca M; Prins, Johan; Tudisco, Cosimo
Ethnicity and gender can affect posterior tibial slope; however, studies on this topic have limitations and are in disagreement. The aim of the present study was to evaluate posterior tibial slope in a large group of consecutive patients, determining whether ethnicity and gender can influence its value. Secondly, to determine intra- and inter-rater reliability of the two radiographic methods adopted. Posterior tibial slope was calculated (rater 1) in lateral view X-rays of the knee according to the posterior tibial cortex (PTC) and tibial proximal anatomical axis (TPAA) methods. Data were matched with ethnicity and gender. For determination of intra- and inter-rater reliability, 50 random X-rays were selected, and blindly measured by two other raters (2 and 3). A total of 581 radiographs were included (413 white and 168 black knees). Comparing white and black subjects, a statistically significant difference was found for both PTC (4.9 ± 1.2 vs 7.1 ± 2.9, p < 0.0001), and for TPAA (7.7 ± 1.1 vs 10.2 ± 3.0, p < 0.0001). In white subjects, an influence of gender was found only for TPAA (6.4 ± 1.1 in males vs 7.6 ± 1.1 in females, p < 0.0001). In black subjects, an influence of gender was found only for PTC (7.4 ± 3.0 in males vs 6.2 ± 2.9 in females, p = 0.01). Intra-rater reliability was good for both methods for rater 1, and very good for rater 2. Inter-rater reliability among the 3 raters was very good for both methods. Differences in posterior tibial slope between different ethnic groups exist. Differences observed between genders are conflicting and might be too small to have implications in clinical practice. The TPAA method is recommended for the evaluation of posterior tibial slope because of higher intra- and inter-rater reliability. Level of evidence 3 Case-control study.
Forster-Horvath, Csaba; Kremo, Valerie; Müller-Gerbl, Magdalena; Nowakowski, Andrej Maria
Despite intensive research, current total knee arthroplasty (TKA) designs do not always provide the correct kinematics for the native joint and thus further optimisation is necessary. Several studies support the importance of malrotation of the tibial components in the failure of TKA. We hypothesise that using the anatomical tibial axis (ATA) to align tibial component rotation on the resected tibial surface may lead to an internal rotation error due to relative anterior shift of the lateral articular surface centre compared to the medial one. The aim of this study was to compare the anatomical tibial axis of the physiological tibial joint surface to the resected one. Twenty formalin-fixed cadaveric knees were obtained for study. After computed tomography scanning the data of each specimen were entered into a standardised coordinate system and virtual bone cuts were performed with 6, 8 and 10 mm resection depths. The positions of the articular surface centres were determined at each resection depth. The lateral articular surface centre had moved anteriorly after the resection by a mean 1.475 mm, while the medial one had not changed significantly. Resecting the tibia at a 6-mm cut and using the transverse tibial axis to align the prosthetic tibial plateau will result in a mean 4.0° (95 % confidence interval, 2.5-5.5°) of internal rotation compared to the uncut tibia. The ATA lies in 6 degrees of external rotation compared to the perpendicular to the posterior tibial condylar axis (PTCA). Graw et al. suggest aligning the tibial component in 10 degrees of external rotation to the latter. Thus, if we accept the above suggestion, the ATA is 4 degrees internally rotated compared to the same line on the resected proximal tibia. These prior studies appear to be in accordance with our findings. We conclude that using the ATA on the resected tibial surface may contribute to an internal rotation error.
Matthieu, L; De Doncker, P; Cauwenbergh, G; Woestenborghs, R; van de Velde, V; Janssen, P A; Dockx, P
Nail-matrix kinetics were studied in 21 patients (19 with onychomycosis, two with tinea corporis) as soon as taking itraconazole (Sporanox) 100 mg daily for up to 7 months. Itraconazole was detected in the distal nail as soon as 1 month after the start of therapy (42 ng/g in fingernails and 16 ng/g in toenails). During the course of treatment, this concentration rose and reached a mean of 160 ng/g in fingernail clippings and 197 ng/g in toenail clippings. Moreover, in fingernails of 12 out of 21 patients and in toenails of six out of 20 patients, itraconazole was detected in the distal nail clippings before full outgrowth of the fastest-growing nail. In most patients, itraconazole was detected in the distal nail clippings earlier than would be expected if the drug were incorporated only via the nail matrix, indicating that in addition to the nail matrix, a second route of penetration into the nail exists, i.e. the nail bed.
Zhuo, Jia L.; Li, Xiao C.
The kidney plays a fundamental role in maintaining body salt and fluid balance and blood pressure homeostasis through the actions of its proximal and distal tubular segments of nephrons. However, proximal tubules are well recognized to exert a more prominent role than distal counterparts. Proximal tubules are responsible for reabsorbing approximately 65% of filtered load and most, if not all, of filtered amino acids, glucose, solutes, and low molecular weight proteins. Proximal tubules also play a key role in regulating acid-base balance by reabsorbing approximately 80% of filtered bicarbonate. The purpose of this review article is to provide a comprehensive overview of new insights and perspectives into current understanding of proximal tubules of nephrons, with an emphasis on the ultrastructure, molecular biology, cellular and integrative physiology, and the underlying signaling transduction mechanisms. The review is divided into three closely related sections. The first section focuses on the classification of nephrons and recent perspectives on the potential role of nephron numbers in human health and diseases. The second section reviews recent research on the structural and biochemical basis of proximal tubular function. The final section provides a comprehensive overview of new insights and perspectives in the physiological regulation of proximal tubular transport by vasoactive hormones. In the latter section, attention is particularly paid to new insights and perspectives learnt from recent cloning of transporters, development of transgenic animals with knockout or knockin of a particular gene of interest, and mapping of signaling pathways using microarrays and/or physiological proteomic approaches. PMID:23897681
Nathoo, Narendra; Sarkar, Atom; Varma, Gandhi; Mendel, Ehud
Although nail-gun injuries are a common form of penetrating low-velocity injury, impalement with barbed nails has been underreported to date. Barbed nails are designed to resist dislodgment once embedded, and any attempt at removal may splay open the barbs along the path of entry, with the potential for significant soft-tissue and neurovascular injury. A 25-year-old man sustained a nail impalement of the cervical spine from accidental discharge of a nail gun. The patient was noted to be fully conscious with no neurological deficits. Cervical Zone 2 impalement was noted, with only the head of the nail visible. Angiography revealed the nail lying just anterior to the right vertebral artery (VA), with compression of the vessel. Preoperatively, analysis of a similar nail revealed that orientation of the head determined position of the barbs. A deep neck dissection was then performed to the lateral aspect of the C-3 body, using the nail as a guide. Prior to removal, the nail was turned 180° to change the position of the barbs, to prevent injury to the VA. Nail removal was uneventful. The authors present a simple technique for treatment of a nail-gun injury with a barbed nail. Prior to removal, radiographic analysis of the impaled nail must be performed to determine the presence of barbs. If possible, the surgeon should request a similar nail for analysis prior to surgery. Last, the treating surgeon must have knowledge of the barbs' position at all times during nail removal, to prevent damage to critical structures.
Qadripur, S A; Schauder, S; Schwartz, P
Black nails caused by Proteus mirabilis were seen in a motor mechanic and in a petrol pump attendant. Proteus mirabilis is a gram-negative bacillus that generates hydrogen sulfide. This compound reacts with traces of metals in the nail plate such as zinc, nickel, cobalt, iron, manganese, tin, copper and lead. Metal sulfides blacken the nail plate. The protracted course of the discoloration over months corresponds to the slow reactions of metals with hydrogen sulfide. The disappearance of the blackening after topical treatment with chinosol, tincture of iodine and chloramphenicol solution supports the etiologic connection between black nails and Proteus mirabilis. Wet and dirty work encourages the colonisation of Proteus mirabilis between nail fold and nail plate.
Brazier, J; Migaud, H; Gougeon, F; Cotten, A; Fontaine, C; Duquennoy, A
We compared on lateral X-rays of 83 healthy knees, 6 methods measuring the tibial sagittal slope. Each method determined the tibial slope according to an independent anatomical axis. The goals of the study were to: 1) detect the differences between the 6 methods; 2) determine if any mathematical relation could be observed between the 6 methods; 3) compare accuracy of proximal anatomical axis versus long anatomical axis to evaluate the tibial slope. 50 healthy patients (83 knees) knees were included in the study. The patients (26 male and 24 females) were 39.3 +/- 15.8 years old. We obtained true lateral X-rays orientated with an image intensifier in order to obtain the exact superposition of the femoral condyles. The measurements were carried out by an observer according to two procedures: 1) by manual goniometric measurements twice; the mean value between both lectures was recorded; 2) with a digitizer (Orthographics TM, Salt Lake City, Ut). We measured the angle between the tangent to the medial tibial plateau and the perpendicular direction to each of the studied anatomical axis: tibial proximal anatomical axis (TPAA); tibial shaft anatomical axis (TSAA); posterior tibial cortex (PTC); fibular proximal anatomical axis (FPAA); fibular shaft axis (FSA); anterior tibial cortex (ATC). The values obtained with the digitizer were used to compare the six methods. The values obtained with the TSAA were considered as reference. Tibial slope values were different with the 6 methods. ATC gave the higher values and PTC the smaller. The difference could be 5 degrees between two methods measuring the same posterior tibial slope. However different, the values obtained with the 6 methods were strongly correlated (R > 0.85; p = 0.0001). We determined mathematical relationships between the values obtained with the 6 methods according to the regression analysis. The correlation with the values obtained with TSAA (reference values) was stronger for TPAA and TPC (respectively R = 0
Siddiq, Ishita; Hughes, Daniel
Yellow nail syndrome is a rare disease and reported mainly in adults. A case of yellow nail syndrome involving an eight-year-old girl with associated discoloured yellowish nails on the fingers and toes, lymphedema and chronic cough, and sputum production is reported. PMID:22332131
Rose, Alice; Birch, Ivan; Kuisma, Raija
To determine whether a motion control running shoe reduces tibial rotation in the transverse plane during treadmill running. An experimental study measuring tibial rotation in volunteer participants using a repeated measures design. Human Movement Laboratory, School of Health Professions, University of Brighton. Twenty-four healthy participants were tested. The group comprised males and females with size 6, 7, 9 and 11 feet. The age range for participants was 19 to 31 years. The total range of proximal tibial rotation was measured using the Codamotion 3-D Movement Analysis System. A one-tailed paired t-test indicated a statistically significant decrease in the total range of proximal tibial rotation when a motion control shoe was worn (mean difference 1.38°, 95% confidence interval 0.03 to 2.73, P=0.04). There is a difference in tibial rotation in the transverse plane between a motion control running shoe and a neutral running shoe. The results from this study have implications for the use of supportive running shoes as a form of injury prevention. Copyright © 2010 Chartered Society of Physiotherapy. Published by Elsevier Ltd. All rights reserved.
Jaiswal, Atin; Kachchhap, Naiman-Deepak; Tanwar, Yashwant S; Kumar, Birendra; Yadav, Sachin K
High-energy tibial plateau fracture poses a significant challenge and difficulty for orthopaedic surgeons. Fracture of tibial plateau involves major weight bearing joint and may alter knee kinematics. Anatomic reconstruction of the proximal tibial articular surfaces, restoration of the limb axis (limb alignment) and stable fixation permitting early joint motion are the goals of the treatment. In cases of complex bicondylar tibial plateau fractures, isolated lateral plating is frequently associated with varus malalignment and better results have been obtained with bilateral plating through dual incisions. However sometimes a complex type of bicondylar tibial plateau fractures is encountered in which medial plateau has a biplaner fracture in posterior coronal plane as well as sagittal plane. In such fractures it is imperative to fix the medial plateau with buttressing in both planes. One such fracture pattern of the proximal tibia managed by triple plating through dual posteromedial and anterolateral incisions is discussed in this case report with emphasis on mechanisms of this type of injury, surgical approach and management.
Caton, Jacques H; Dejour, David
The aim of this study was to present the different surgical procedures of tibial tubercle osteotomies for patellar instability or patellar mispositioning such as patella alta or patella infera. This study analysed the Caton-Deschamps index used for assessment of vertical patella height in order to make a precise plan for tibial tuberosity osteotomies. This study included 61 knees (50 patients) treated for patellar instability with patella alta and 24 patients treated for patella infera of mechanical origin. The results of medial transfer of the tibial tuberosity, with or without distal transfer in cases of patellar instability with patella alta, gives excellent results for stability in 76.8% of the cases. The results of the proximal transfer of the tibial tuberosity in cases of patella infera were excellent or good in 80% of the cases in our series of 24 patients. A precise preoperative plan is needed with determination of the vertical patellar height using the Caton-Deschamps index and the situation of the tibial tuberosity and the Tibial Tubercle to Trochlear Groove distance (TT-TG) of the knee on CT scan in order to obtain satisfactory results.
The aim of this study was to present the different surgical procedures of tibial tubercle osteotomies for patellar instability or patellar mispositioning such as patella alta or patella infera. This study analysed the Caton–Deschamps index used for assessment of vertical patella height in order to make a precise plan for tibial tuberosity osteotomies. This study included 61 knees (50 patients) treated for patellar instability with patella alta and 24 patients treated for patella infera of mechanical origin. The results of medial transfer of the tibial tuberosity, with or without distal transfer in cases of patellar instability with patella alta, gives excellent results for stability in 76.8% of the cases. The results of the proximal transfer of the tibial tuberosity in cases of patella infera were excellent or good in 80% of the cases in our series of 24 patients. A precise preoperative plan is needed with determination of the vertical patellar height using the Caton–Deschamps index and the situation of the tibial tuberosity and the Tibial Tubercle to Trochlear Groove distance (TT-TG) of the knee on CT scan in order to obtain satisfactory results. PMID:20066411
Yadav, Savita; Khullar, Geeti; Dogra, Sunil
Onychoheterotopia is an uncommon condition in which nail tissue is found beyond the common nail unit of the digits of the hands and feet, most often on the fifth digit of the hand. It represents an extra and independent nail that can be present either congenitally, or more commonly, acquired following trauma. The exact pathogenesis of the congenital type is undetermined. We report a 25-year-old male with multiple congenital ectopic nails of the toes since birth, which has not been reported before.
Maeva, A. R.; Bakulin, E. Y.; Denisova, L. A.; Maev, R. Gr.
Investigation of a human fingernail and the extraction of the data on its microstructure and elastic properties is important in three main aspects. First of all, various diseases of the nail can be differentiated more precisely; second of all, it is possible to non-invasively track during time the effects of a cosmetic product upon the nail; third of all, because various processes in the organism have a strong influence upon the nail plate growth, the monitoring of the nail morphology and its mechanical properties may be used as additional information for the diagnosis of a number of medical disorders, such as systemic sclerosis, psoriasis, chronic hand eczema, anemia etc. The aim of the present study was to carry out a detailed ultrasound investigation in the high-frequency range (25-50 MHz) of a human nail including micro-anatomical structure imaging and ultrasound velocity evaluation, using B-scans obtained with a scanning acoustic microscope. On the images, exact topology of the nail, nail matrix and the underlying bone have been revealed. Additionally, a certain type of inclined internal layering along the nails of some individuals has been found, which was not reported in previous ultrasonic studies of the nail.
Dufrene, Brad A; Steuart Watson, T; Kazmerski, Jennifer S
This study applied functional analysis methodology to nail biting exhibited by a 24-year-old female graduate student. Results from the brief functional analysis indicated variability in nail biting across assessment conditions. Functional analysis data were then used to guide treatment development and implementation. Treatment included a simplified habit reversal package that was modified based on results of the functional analysis. Following treatment implementation, nail biting decreased as evidenced by consistent nail growth and participant self-recorded data. Results are discussed in terms of treatment utility of functional analysis methodology for novel populations and response topographies.
Vignes, Stéphane; Baran, Robert
Yellow nail syndrome (YNS; OMIM 153300, ORPHA662) is a very rare disorder that almost always occurs after 50 years of age but a juvenile or familial form has also been observed. YNS is diagnosed based on a triad associating yellow nail discoloration, pulmonary manifestations (chronic cough, bronchiectasia, pleural effusion) and lower limb lymphedema. Chronic sinusitis is frequently associated with the triad. YNS etiology remains unknown but a role of lymphatic impairment is usually evoked. YNS is more frequently isolated but may be associated in rare cases with autoimmune diseases, other clinical manifestations implicating lymphatic functions or cancer and, hence, is also considered a paraneoplastic syndrome. YNS management is symptomatic and not codified. YNS can resolve spontaneously. Oral vitamin E alone or even better when associated with triazole antifungals may achieve partial or total disappearance of nail discoloration. Pleural effusion can be treated surgically, with decortication/pleurectomy or pleurodesis. Antibiotic prophylaxis is prescribed for bronchiectasia with chronic sputum production. Lymphedema treatment is based on low-stretch bandages and the wearing of elastic compression garments combined with skin care, exercises and, as needed, manual lymph drainage.
Bagherifard, Abolfazl; Jabalameli, Mahmoud; Hadi, Hosseinali; Rahbar, Mohammad; Minator Sajjadi, Mohammadreza; Jahansouz, Ali; Karimi Heris, Hossein
Background Tibial plateau fractures can be successfully fixed utilizing 3.5 mm locking plates. However, there are some disadvantages to using these plates. Objectives In the current prospective study, we investigated the outcome of treating different types of tibial plateau fractures with 3.5 mm simple plates which, to our knowledge, has not been evaluated in previous studies. Materials and Methods Between 2011 and 2013, 32 patients aged 40 ± 0.2 years underwent open reduction and internal fixation for tibial plateau fractures with 3.5 mm simple plates. The patients were followed for 16.14 ± 2.1 months. At each patient’s final visit, the articular surface depression, medial proximal tibial angle, and slope angle were measured and compared with measurements taken early after the operation. The functional outcomes were measured with the WOMAC and Lysholm knee scores. Results The mean union time was 13 ± 1.2 weeks. The mean knee range of motion was 116.8° ± 3.3°. The mean WOMAC and Lysholm scores were 83.5 ± 1.8 and 76.8 ± 1.6, respectively. On the early postoperative and final X-rays, 87.5% and 84% of patients, respectively, had acceptable reduction. Medial proximal tibial and slope angles did not change significantly by the last visit. No patient was found to have complications related to the type of plate. Conclusions In this case series study, the fixation of different types of tibial plateau fractures with 3.5 mm simple non-locking and non-precontoured plates was associated with acceptable clinical, functional, and radiographic outcomes. Based on the advantages and costs of these plates, the authors recommend using 3.5 mm simple plates for different types of tibial plateau fractures. PMID:27626010
Objective To compare the Short Musculoskeletal Function Assessment Dysfunction Index and the Short Form-36 Physical Component Summary scores among patients undergoing operative management of tibial fractures. Study Design and Setting Between July 2000 and September 2005, we enrolled 1319 skeletally mature patients with open or closed fractures of the tibial shaft that were managed with intramedullary nailing. Patients were asked to complete the Short Musculoskeletal Function Assessment and Short Form-36 at discharge and 3, 6, and 12 months post surgical fixation. Results Short Musculoskeletal Function Assessment Dysfunction Index and Short Form-36 Physical Component Summary scores were highly correlated at 3, 6, and 12 months post surgical fixation. The difference in mean standardized change scores for the Short Musculoskeletal Function Assessment Dysfunction Index and the Short Form-36 Physical Component Summary, from 3 to 12 months post-surgical fixation, was not statistically significant. Both the Short Musculoskeletal Function Assessment Dysfunction Index and Short Form-36 Physical Component Summary scores were able to discriminate between healed and non-healed tibial fractures at 3, 6, and 12 months post surgery. Conclusion In patients with tibial shaft fractures, the Short Musculoskeletal Function Assessment Dysfunction Index offered no important advantages over the Short Form-36 Physical Component Summary score. These results, along with the usefulness of the Short Form-36 for comparing populations, recommends the Short Form-36 for assessing physical function in studies of patients with tibial fractures. PMID:19364637
Busse, Jason W; Bhandari, Mohit; Guyatt, Gordon H; Heels-Ansdell, Diane; Mandel, Scott; Sanders, David; Schemitsch, Emil; Swiontkowski, Marc; Tornetta, Paul; Wai, Eugene; Walter, Stephen D
To compare the Short Musculoskeletal Function Assessment Dysfunction Index (SMFA DI) and the Short Form-36 Physical Component Summary (SF-36 PCS) scores among patients undergoing operative management of tibial fractures. Between July 2000 and September 2005, we enrolled 1,319 skeletally mature patients with open or closed fractures of the tibial shaft that were managed with intramedullary nailing. Patients were asked to complete the SMFA Questionnaire and SF-36 at discharge and 3, 6, and 12 months post-surgical fixation. The SMFA DI and SF-36 PCS scores were highly correlated at 3, 6, and 12 months post-surgical fixation. The difference in the mean standardized change scores for SMFA DI and SF-36 PCS, from 3 to 12 months post-surgical fixation, was not statistically significant. Both the SMFA DI and SF-36 PCS scores were able to discriminate between healed and nonhealed tibial fractures at 3, 6, and 12 months postsurgery. In patients with tibial-shaft fractures, the SMFA DI offered no significant advantages over the SF-36 PCS score. These results, along with the usefulness of SF-36 for comparing populations, recommend the SF-36 for assessing physical function in studies of patients with tibial fractures.
Ho, Kelvin Lor Kah; Sing, Nicholas Yeoh Ching; Wong, Khai Phang; Huat, Andy Wee Teck
To measure the intracompartmental pressures surrounding tibial fractures not exhibiting any clinical evidence of compartment syndrome. Our hypothesis was that pressures often exceed the recommended threshold of fasciotomy despite the absence of compartment syndrome, and hence diagnosis based on pressure measurements alone is unreliable. Thirteen consecutive patients with closed tibial shaft fractures without clinical suspicion of compartment syndrome, and who were planned for intramedullary nailing, were prospectively enrolled. Compartment pressures ( P) in all four compartments of the affected leg were measured at the start of surgery and immediately after tibial reaming, and differential pressures (delta P) were calculated based on the diastolic blood pressure prior to induction of anaesthesia. No patients required reoperation in the post-operative period, as a result of an undiagnosed compartment syndrome. Using commonly quoted threshold pressure criteria, 62% (using P > 30 mmHg) and 23% of patients (using delta P < 30 mmHg) have been incorrectly diagnosed with compartment syndrome. We conclude that raised compartment pressures are frequently seen in patients with tibial shaft fractures; but in most cases, it does not equate to the presence of compartment syndrome. Diagnosis of compartment syndrome based on intracompartmental pressure measurements alone may result in unnecessary fasciotomies in a sizeable number of patients. Compartment syndrome remains a clinical diagnosis, and one which always needs to be considered when managing tibial fractures.
Papakostidis, Costas; Kanakaris, Nikolaos K; Pretel, Juan; Faour, Omar; Morell, Daniel Juan; Giannoudis, Peter V
The aim of the present study was to comparatively analyse certain outcome measures of open tibial fractures, stratified per grade of open injury and method of treatment. For this purpose, a systematic review of the English literature from 1990 until 2010 was undertaken, comprising 32 eligible articles reporting on 3060 open tibial fractures. Outcome measures included rates of union progress (early union, delayed union, late union and non-union rates) and certain complication rates (deep infection, compartment syndrome and amputation rates). Statistical heterogeneity across component studies was detected with the use of Cochran chi-square and I(2) tests. In the absence of significant statistical heterogeneity a pooled estimate of effect size for each outcome/complication of interest was produced. All component studies were assigned on average a moderate quality score. Reamed tibial nails (RTNs) were associated with significantly higher odds of early union compared with unreamed tibial nails (UTNs) in IIIB open fractures (odds ratio: 12, 95% CI: 2.4-61). Comparing RTN and UTN modes of treatment, no significant differences were documented per grade of open fractures with respect to both delayed and late union rates. Surprisingly, nonunion rates in IIIB open fractures treated with either RTNs or UTNs were lower than IIIA or II open fractures, although the differences were not statistically significant. Significantly increased deep infection rates of IIIB open fractures compared with all other grades were documented for both modes of treatment (RTN, UTN). However, lower deep infection rates for IIIA open fractures treated with RTNs were recorded compared with grades I and II. Interestingly, grade II open tibial fractures, treated with UTN, presented significantly greater odds for developing compartment syndrome than when treated with RTNs. Our cumulative analysis, providing for each grade of open injury and each particular method of treatment a summarised estimate of
Hoffmann, Stefanie; Gerber, Claus; von Oldenburg, Geert; Kessler, Manuel; Stephan, Daniel; Augat, Peter
To extend the indications of intramedullary nails for distal or proximal fractures, nails with angle stable locking options have been developed. Studies on the mechanical efficacy of these systems have been inconsistent likely due to confounding variables such as number, geometry, or orientation of the screws, as well as differences in the loading mode. Therefore, the aim of this study was to quantify the effect of angular stability on the mechanical performance of intramedullary nails. The results could then be compared with the effects of various locking screw parameters and loading modes. A generic model was developed consisting of artificial bone material and titanium intramedullary nail that provided the option to systematically modify the locking screw configuration. Using a base configuration, the following parameters were varied: number of screws, distance and orientation between screws, blocking of screws, and simulation of freehand locking. Tension/compression, torsional, and bending loads were applied. Stiffness and clearance around the zero loading point were determined. Angular stability had no effect on stiffness but completely blocked axial clearance (p=0.003). Simulation of freehand locking reduced clearance for all loading modes by at least 70% (p<0.003). The greatest increases in torsional and bending stiffness were obtained by increasing the number of locking screws (up to 80%, p<0.001) and by increasing the distance between them (up to 70%, p<0.001). In conclusion, our results demonstrate that the mechanical performance of IM nailing can be affected by various locking parameters of which angular stability is only one. While angular stability clearly reduces clearance of the screw within the nail, mechanical stiffness depends more on the number of screws and their relative distance. Thus, optimal mechanical performance in IM nailing could potentially be obtained by combining angular stability with optimal arrangement of locking screws.
Tyllianakis, Minos; Tsoumpos, Pantelis; Anagnostou, Kostas; Konstantopoulou, Anna; Panagopoulos, Andreas
Purpose: Distal interlocking is regarded as an inherent part of the antegrade humeral nailing technique, but it exposes both the patient and surgeon to radiation, is time consuming, and has a potential risk of damaging neurovascular structures. We have presented our technique of diaphyseal humeral nailing without any distal interlocking in this paper. Materials and Methods: We have presented a series of 64 consecutive patients (33 male and 31 female, mean age: 41.5 years) with humeral shaft fractures treated with antegrade rigid intramedullary nailing without distal interlocking following a strict intra and postoperative protocol. According to the AO classification, there were 36 type A fractures, 22 type B, and 6 type C. Nails were inserted unreamed or by using limited proximal reaming and they were fitted as snuggly as possible into the medullary canal. After impaction of the nail into the fossa, we carefully tested rotational stability of fixation by checking any potential external rotation when the arm was slightly turned externally and left to the gravity forces. We were ready to add distal screws, but that was not required in these cases. Follow-up assessment included fracture union, complications and failures, and the final clinical outcome at minimum 2-year follow-up using the parameters of the constant score. Results: All fractures, except two, united between the 4th and 5th postoperative month. In one case, nail was exchanged with plate, and, in another, a larger nail was used at a second surgery. Shoulder function according to constant score, at a minimum of 2-year follow-up, was excellent or very good in 93.7% of the patients. Conclusions: Provided that some technical issues are followed, the method reduces intraoperative time and radiation exposure and avoids potential damage to neurovascular structures. PMID:23960365
Moshiashvili, B I
80 cases of pathological reconstruction of the tibia in young men at the age of 18--20 are described. The pathology developed as a result of intense regular physical exercise. In 53 patients the process was localized in the upper third of the tibia, in 20--in the middle third and in 7--in the lower third of the bone. In 6 cases the fracture of the tibial proximal metaphysis happened against the background of pathological reconstruction of the tibia; 3 of them sustained simultaneously a fracture of the fibular head. Some recommendations of practical importance are suggested.
Zuo, Kangkang; Qin, Wei; Guo, Qing; Palati-Ababaikeli; Qiao, Peiliu; Shen, Mingquan; Yin, Lele; Pan, Qilin; Xu, Xiaoxiong
To explore the value of electromagnetic navigation interlocking intramedullary nail in the treatment of femoral shaft fracture. Between July 2012 and October 2013, 53 cases of femoral shaft fracture were treated. There were 40 males and 13 females, aged 16-52 years (mean, 38.3 years). The causes of injury were traffic accident in 28 cases, falling from height in 11 cases, falling in 7 cases, crush injury in 4 cases, and other in 3 cases. Of 53 cases, there were 3 cases of open fracture (Gustilo I degree) and 50 cases of closed fracture. Fracture was located in the proximal femur in 17 cases, middle femur in 29 cases, and distal femur in 7 cases. According to Winquist classification, 7 cases were rated as type I, 8 cases as type II, 22 cases as type III, and 16 cases as type IV; according to AO classification, 18 cases were rated as type 32-A, 28 cases as type 32-B, and 7 cases as type 32-C. The time from injury to operation was 3-11 days (mean, 5 days). Distal interlocking intramedullary nail was implanted using electromagnetic navigation. The distal locking nail operation with interlocking intramedullary nail was successfully completed under electromagnetic navigation; the one-time success rate of distal locking nail operation reached 100%; and the locking nail time was 5.0-9.5 minutes (mean, 7.0 minutes). Healing of incision by first intention was obtained after operation, and no complication of skin necrosis, infection, and sinus tract occurred. Fifty-three cases were all followed up 5-12 months (mean, 9 months). One case had hip pain and weaken middle gluteal muscle strength, and the symptoms disappeared after removing the nail. During the follow-up period, no broken nails, nail exit, infection, or re-fracture occurred. All fractures achieved clinical healing, and the healing time was 8-22 weeks (mean, 14.5 weeks). In 49 patients followed up 8 months, the Lysholm score was excellent in 44 cases, good in 4 cases, and acceptable in 1 case, with an excellent and
Song, Sang-Heon; Agashe, Mandar Vikas; Huh, Young-Jae; Hwang, Soon-Young; Song, Hae-Ryong
Bilateral tibial lengthening has become one of the standard treatments for upper segment-lower segment disproportion and to improve quality of life in achondroplasia. We determined the effect of tibial lengthening on the tibial physis and compared tibial growth that occurred at the physis with that in non-operated patients with achondroplasia. We performed a retrospective analysis of serial radiographs until skeletal maturity in 23 achondroplasia patients who underwent bilateral tibial lengthening before skeletal maturity (lengthening group L) and 12 achondroplasia patients of similar height and age who did not undergo tibial lengthening (control group C). The mean amount of lengthening of tibia in group L was 9.2 cm (lengthening percentage: 60%) and the mean age at the time of lengthening was 8.2 years. The mean duration of follow-up was 9.8 years. Skeletal maturity (fusion of physis) occurred at 15.2 years in group L and at 16.0 years in group C. The actual length of tibia (without distraction) at skeletal maturity was 238 mm in group L and 277 mm in group C (p = 0.03). The mean growth rates showed a decrease in group L relative to group C from about 2 years after surgery. Physeal closure was most pronounced on the anterolateral proximal tibial physis, with relative preservation of the distal physis. Our findings indicate that physeal growth rate can be disturbed after tibial lengthening in achondroplasia, and a close watch should be kept for such an occurrence-especially when lengthening of more than 50% is attempted.
Kose, Ozkan; Guler, Ferhat; Gurcan, Serkan; Arik, Hasan Onur; Baz, Ali Bulent; Akalin, Serdar
The purpose of this retrospective study is to evaluate the cosmetic results of wedge resection of the nail matrix (Winograd technique) in the treatment of ingrown toenail. This study retrospectively reviewed medical charts of 68 patients with 75 ingrown toenails who underwent surgical correction with the Winograd technique between January, 2008, and December, 2009, at the Orthopaedics and Traumatology Department, Antalya Education and Research Hospital. For the final follow-up, patients were contacted by telephone and completed a telephone questionnaire. Recurrence, cosmetic results, and satisfaction of the patients were the major outcome measures. There was recurrence in 9 patients (13.2%). The mean recurrence time was 6.7 months (range = 2-12 months). All recurrences involved the lateral border of the toenail. Cosmetic ratings were statistically lower in female patients (P = .005). The reasons for poor and acceptable cosmetic results were proximal-incision scar and narrowing of the nail plate. Wedge resection of nail matrix has a considerably high recurrence rate. Furthermore, narrowing of the nail plate is a disadvantage of this procedure. All patients should be informed about the possibility of recurrence and disfigurement in their toenails (narrow nail plate). Particularly, female patients who care about the cosmesis may be dissatisfied with this surgical technique.
Baden, H P; Kvedar, J C
Nail and certain layers of the hair follicle form cornified envelopes (CEs) that morphologically resemble those in epidermis. We have been studying two unique precursors of the CE in human epidermis, pancornulin and sciellin. Antibodies to these proteins stained the more central cells of the outer root sheath of the ostium and isthmus of the follicle where CEs are found. Staining was also observed with these antibodies in the inner root sheath, where CEs were thought not to be present. Using immunoelectron microscopy, the staining by the sciellin antibody was at the cell periphery, but this technique did not work with the antibody to pancornulin. The antibody to pancornulin reacted to the nail fold and proximal matrix, whereas the one to sciellin reacted with the nail fold, matrix, and bed. Similar reactions were observed to monkey, sheep, and cow nail. These results suggest that envelope precursor may have an additional function in the hair follicle as well as contributing to the CE in hair and nail.
Salim, Rodrigo; Salzler, Matthew J; Bergin, Mark A; Zheng, Liying; Carey, Robert E; Kfuri, Mauricio; Zhang, Xudong; Harner, Christopher D
Currently, placement of the tibial tunnel for arthroscopic transtibial posterior cruciate ligament (PCL) reconstruction relies on a limited arthroscopic view of the native insertion or the use of intraoperative imaging. No widely accepted method exists for intraoperative determination of PCL tibial tunnel placement, and current descriptions are cumbersome. To identify the center of the PCL's anatomic tibial insertion site as a percentage of the PCL facet length on a lateral radiograph of the knee so that it may be reliably located in the sagittal plane during surgical reconstruction. Descriptive laboratory study. Twenty fresh-frozen cadaveric knees were dissected and the tibial insertions of the PCL were digitized with an optical tracing system. The digitized PCL footprints were mapped onto 3-dimensional computed tomography-acquired tibial models, and their center points were determined. A K-wire was then inserted into the center of the PCL's tibial insertion under direct visualization, a direct lateral radiograph was obtained, and the center point was measured. The center locations for both methods were defined as a percentage of PCL facet length from anterior and proximal to posterior and distal, and intraobserver and interobserver reliability was tested with 4 different observers. The average location of the PCL center on the 3-dimensional bone model method was 71.7%±5.6% along the PCL facet from anterior/proximal to posterior/distal. In the lateral radiographic method, the center of the PCL was at an average of 69.7%±4.9% of the facet length. There was no significant difference between the percentage measurements of the 2 methods (P=.13). Interobserver reliability (κ=0.57) and intraobserver reliability (κ=0.71) were moderate to strong. Locating the center of the tibial PCL insertion with fluoroscopy at a point that is 70% of the PCL tibial facet length on a true lateral radiograph is a reliable method for locating the PCL tibial insertion. The method
The nail carries a significant cosmetic impact and plays an integral role in the multi-billion dollar salon industry. This review focuses on nail disorders that are induced by nail cosmetics via procedures, equipment, or materials that are intended to beautify or adorn the nail. The authors give specific attention to clinical presentations that are common, novel, and underreported, but may be misdiagnosed easily by the competent dermatologist. They also provide an update on the controversies surrounding contemporary nail cosmetic procedures, such as acrylic and gel manicures. PMID:27462387
Maheshwari, Aditya V; Jelinek, James S; Seibel, Nita L; Meloni-Ehrig, Aurelia M; Kumar, Dhruv; Henshaw, Robert M
Multifocal or multicentric osteosarcoma (OS) has been described as tumor occurrence at two or more sites in a patient without visceral metastasis. These may be synchronous (more than one lesion at presentation) or metachronous (new tumor developing after the initial treatment). The incidence of multifocal OS has ranged from 1.5 to 5.4% in large series, with the synchronous type being rarer. Similarly, periosteal OS is another rare subtype of surface OS and constitutes less than 2% of all OS. An 11-year-old female was diagnosed with bilateral synchronous tibial periosteal OS, which were confirmed by CT-guided biopsies. After neoadjuvant chemotherapy, the patient underwent a staged wide local resection of the tumors. The defect was reconstructed with a proximal tibial replacement on the left side and autologous bone grafting on the right side. The patient did well after surgery and is free of disease at 5.5 years of follow-up. However, her brother also developed a right tibial periosteal osteosarcoma 4 years after her index surgery. Genetic analysis of blood sample from both patients showed a similar missense mutation in at least one allele of TP53 gene (exon 8). To the best of our knowledge, a case of bilateral 'synchronous' periosteal OS with a familial incidence has not been reported before.
Singal, Archana; Daulatabad, Deepashree
Nail tic disorders are classic examples of overlap between the domains of dermatology and psychiatry. They are examples of body-focused repetitive behaviors in which there is an irresistible urge or impulse to perform a certain behavior. The behavior is reinforced as it results in some degree of relief and pleasure. Nail tic disorders are common, yet poorly studied and understood. The literature on nail tic disorders is relatively scarce. Common nail tics include nail biting or onychophagia, onychotillomania and the habit tic deformity. Some uncommon and rare nail tic disorders are onychoteiromania, onychotemnomania, onychodaknomania and bidet nails. Onychophagia is chronic nail biting behavior which usually starts during childhood. It is often regarded as a tension reducing measure. Onychotillomania is recurrent picking and manicuring of the fingernails and/or toenails. In severe cases, it may lead to onychoatrophy due to irreversible scarring of the nail matrix. Very often, they occur in psychologically normal children but may sometimes be associated with anxiety. In severe cases, onychotillomania may be an expression of obsessive-compulsive disorders. Management of nail tic disorders is challenging. Frequent applications of distasteful topical preparations on the nail and periungual skin can discourage patients from biting and chewing their fingernails. Habit-tic deformity can be helped by bandaging the digit daily with permeable adhesive tape. Fluoxetine in high doses can be helpful in interrupting these compulsive disorders in adults. For a complete diagnosis and accurate management, it is imperative to assess the patient's mental health and simultaneously treat the underlying psychiatric comorbidity, if any.
Shetty, A A; Tindall, A J; Nickolaou, N; James, K D; Ignotus, P
In tibial tubercle transfer, surgery drills and screws can put the popliteal vessels at risk if the posterior cortex is breached. This complication can be devastating. We have looked at arteriograms of 50 knees and identified a safe zone through which an instrument can be passed with more confidence. In our study we found no vessels directly posterior to the supero-medial aspect of the proximal metaphysis in any knee. Whilst care must still be taken, this area will allow surgeons greater confidence to obtain a stronger bicortical hold with any fixation device.
Eberle, S; Bauer, C; Gerber, C; von Oldenburg, G; Augat, P
The purpose of this study was to address the question of how the stability of a proximal hip fracture determines the fatigue and failure mechanism of an intramedullary implant. To answer this question, mechanical experiments and finite element simulations with two different loading scenarios were conducted. The two load scenarios differed in the mechanical support of the fracture by an artificial bone sleeve, representing the femoral head and neck. The experiments confirmed that an intramedullary nail fails at a lower load in an unstable fracture situation in the proximal femur than in a stable fracture. The nails with an unstable support failed at a load 28 per cent lower than the nails with a stable support by the femoral neck. Hence, the mechanical support of a fracture is crucial to the fatigue failure of an implant. The simulation showed why the fatigue fracture of the nail starts at the aperture of the lag screw. It is the location of the highest von Mises stress, which is the failure criterion for ductile materials.
Wang, Haosen; Hao, Zhixiu; Wen, Shizhu
Intramedullary interlocking nail is an effective treatment for tibial diaphyseal fracture. The contact between medullary rod and diaphyseal cortex is able to enhance fracture stability. However, how and to what degree the contact affects fracture healing and subsequent bone remodeling is still unclear. To investigate this, fracture healing and remodeling algorithms were combined, improved, and used to simulate the healing and remodeling processes in a transverse tibial diaphyseal fracture fixed with an intramedullary interlocking nail device. Two different diaphyseal fracture statuses, three different initial loading levels, and two nail materials were considered. The results showed that the medullary contact could significantly enhance the fixation stability; the strain reduction was up to 80% in the initial granulation callus. However, low initial loading level was found to be a more potential risk factor for the insufficient loading-induced nonunion other than medullary contact and stiffer nail material. Furthermore, the stabilizing effect of medullary contact diminished when stiff bone tissue formed in the callus; thus, the remodeling in the long-term was not affected by medullary contact. Copyright © 2016 John Wiley & Sons, Ltd.
Fogarty, A. B.; Yeates, H. A.
The AO interlocking nail was introduced to the Ulster Hospital, Dundonald in 1988 and since then has been used in over 50 patients with femoral shaft fractures. We have reviewed 45 patients with 46 femoral shaft fractures treated between June 1988 and April 1990. These included four compound fractures and 13 comminuted fractures. The results compare favourably with other series. The union rate was 98% and there were no instances of deep infection. The alternative treatment methods available are discussed along with a review of the relevant literature. Images Fig 3 Fig 5 PMID:1785145
Vugia, Duc J; Jang, Yvonne; Zizek, Candi; Ely, Janet; Winthrop, Kevin L; Desmond, Edward
In 2000, an outbreak of Mycobacterium fortuitum furunculosis affected customers using whirlpool footbaths at a nail salon. We swabbed 30 footbaths in 18 nail salons from 5 California counties and found mycobacteria in 29 (97%); M. fortuitum was the most common. Mycobacteria may pose an infectious risk for pedicure customers.
Jang, Yvonne; Zizek, Candi; Ely, Janet; Winthrop, Kevin L.; Desmond, Edward
In 2000, an outbreak of Mycobacterium fortuitum furunculosis affected customers using whirlpool footbaths at a nail salon. We swabbed 30 footbaths in 18 nail salons from 5 California counties and found mycobacteria in 29 (97%); M. fortuitum was the most common. Mycobacteria may pose an infectious risk for pedicure customers. PMID:15829204
Dufrene, Brad A.; Watson, T. Steuart; Kazmerski, Jennifer S.
This study applied functional analysis methodology to nail biting exhibited by a 24-year-old female graduate student. Results from the brief functional analysis indicated variability in nail biting across assessment conditions. Functional analysis data were then used to guide treatment development and implementation. Treatment included a…
Goossens, D. J.; Studer, A. J.; Stachurski, Z. H.
Neutron diffraction allows nondestructive testing of the bulk microstructure of mechanical components. The microstructures of horseshoe nails made through three different processes have been explored as a function of position along the nail. Despite all nails being made of similar plain low-carbon steel and being process annealed after manufacture, the microstructures are far from the same. Nails made from strip, using a cold forging stamping process, show narrower diffraction peaks indicating a narrower distribution of lattice parameters and also show diffraction peak intensity ratios closer to those expected for unstrained steel. Thus, the distribution of the orientation of grains in these nails is closer to that of undistorted steel compared to nails made through the other two processes considered—one a drawing from wire and the other a combination of rolling and cold forging. The blades of the drawn nails showed little preferred orientation but the converse was true in the heads. Differing patterns of preferred orientation suggest that the various manufacturing approaches result in substantially different mechanical advantages for the three types of nails, a result in accord with mechanical testing.
Dufrene, Brad A.; Watson, T. Steuart; Kazmerski, Jennifer S.
This study applied functional analysis methodology to nail biting exhibited by a 24-year-old female graduate student. Results from the brief functional analysis indicated variability in nail biting across assessment conditions. Functional analysis data were then used to guide treatment development and implementation. Treatment included a…
L bend for valgus curvature. The end caps on both the short and long nail are offered in three sizes: standard, +5mm and +10mm. Both nails are...of the iliac crest . Once the incision is made, a cannulated curved awl is used to open the medullary canal. When reaming the medullary canal...forces produce a bending moment on the proximal end of the femur. By simulating this load, the bone and gamma nail are tested to the limits. The
Furlan, D; Pogorelić, Z; Biočić, M; Jurić, I; Budimir, D; Todorić, J; Šušnjar, T; Todorić, D; Meštrović, J; Milunović, K P
To demonstrate the effectiveness of intramedullary fixation of displaced long bones shaft fractures in skeletally immature children using the elastic stable intramedullary nails. The case records of 173 children who underwent fixation with titanium intramedulary nails because of long bones fractures were reviewed. The average age of the patients was 11.7 years, and mean follow-up was 41.3 months. There were 55 humeral, 42 forearm, 42 femoral and 36 tibial fractures. Subjective satisfaction was assessed. All patients achieved complete healing at a mean of 7.5 weeks. Complications were recorded in 11 (6.3%) patients and included: one neuropraxia, six entry site skin irritations, two protrusions of the wires through the skin and two skin infections at the entry site. In a subjective measure of outcome at follow-up, 89% of patients were very satisﬁed and 11% satisﬁed; no patients reported their outcome as not satisﬁed. The implants were removed at a median time of six months from the index operation. Elastic Stable Intra-medullary Nailing is the method of choice for the pediatrics patients, because it is minimaly invasive and shows very good functional and cosmetic results. It allows an early functional and cast-free follow-up with a quick pain reduction.
Chung, Kyu Sung; Lee, Jin Kyu; Lee, Hee Jae; Choi, Choong Hyeok
Severe uncontained tibial bone defects occurring during total knee arthroplasty are challenging, and which treatment method is the best remains unknown. In this study, clinical and radiographic outcomes of double metal blocks augmentation were examined. Between 2004 and 2012, double metal blocks augmentation was carried out in 17 patients with severe asymmetric uncontained tibial bone defects. The first block was attached to the tibial tray with screws, and then the second block was cemented to the first block. Out of 17 patients, 13 (8 primary, 5 revision) were available for final follow-up at a median of 69 months (range 24-99). For clinical assessment, range of motion and Knee Society score were evaluated preoperatively and annually thereafter. At the final follow-up, Western Ontario and McMaster Universities Osteoarthritis Index, Oxford knee, Short Form-36, Lower extremity functional scale, and Lower extremity activity scale scores were evaluated. Radiographic assessment for radiolucent lines at the block-cement-bone interfaces and signs of failure was performed annually using fluoroscopy and standard radiographs. Range of motion and Knee Society score were significantly improved post-operatively. Other clinical outcomes were favourable. Radiolucent lines were seen on fluoroscopy in three knees, but no sign of failure, such as loosening, collapse, or instability, was observed at the final follow-up. Double metal blocks augmentation is a favourable and useful method, which does not cause mechanical failure or protrusion of the prosthetic because of its modularity, to manage severe asymmetric uncontained proximal tibial bone defects >15 mm in total knee arthroplasty. Case series, Level IV.
Tosun, Haci Bayram; Serbest, Sancar; Uludag, Abuzer; Gumustas, Seyitali; Celik, Suat
There are many techniques for limb lengthening. Lengthening over a plate is an alternative choice of fixation in children or when nailing is difficult. We present a new technique for tibial lengthening with using a monolateral external fixator over a lengthening plate.Lengthening over an intramedullary nail is a commonly used method in patients with short stature or limb-length discrepancy. However, in patients with a narrow and excessively sclerotic intramedullary cavity in the pediatric age group where the skeletal system has not yet fully developed, difficulties have been observed in lengthening methods with nailing.Therefore, in these cases, the use of lengthening techniques over a plate is an alternative treatment option. Nevertheless, in lengthening techniques over a plate, if one side of the osteotomy area cannot be fixed, associated mechanical axis problems have been reported.We applied tibia lengthening with external fixator assistance over a custom-made lengthening plate in a patient with sequelae of poliomyelitis. This new lengthening technique applied over a plate could be the solution to the problems observed in other lengthening techniques over a plate.
Stinton, S K; Siebold, R; Freedberg, H; Jacobs, C; Branch, T P
The purpose of this study was to: (1) determine whether a robotic tibial rotation device and an electromagnetic tracking system could accurately reproduce the clinical dial test at 30° of knee flexion; (2) compare rotation data captured at the footplates of the robotic device to tibial rotation data measured using an electromagnetic sensor on the proximal tibia. Thirty-two unilateral ACL-reconstructed patients were examined using a robotic tibial rotation device that mimicked the dial test. The data reported in this study is only from the healthy legs of these patients. Torque was applied through footplates and was measured using servomotors. Lower leg motion was measured at the foot using the motors. Tibial motion was also measured through an electromagnetic tracking system and a sensor on the proximal tibia. Load-deformation curves representing rotational motion of the foot and tibia were compared using Pearson's correlation coefficients. Off-axis motions including medial-lateral translation and anterior-posterior translation were also measured using the electromagnetic system. The robotic device and electromagnetic system were able to provide axial rotation data and translational data for the tibia during the dial test. Motion measured at the foot was not correlated to motion of the tibial tubercle in internal rotation or in external rotation. The position of the tibial tubercle was 26.9° ± 11.6° more internally rotated than the foot at torque 0 Nm. Medial-lateral translation and anterior-posterior translation were combined to show the path of the tubercle in the coronal plane during tibial rotation. The information captured during a manual dial test includes both rotation of the tibia and proximal tibia translation. All of this information can be captured using a robotic tibial axial rotation device with an electromagnetic tracking system. The pathway of the tibial tubercle during tibial axial rotation can provide additional information about knee
Frey, Steven; Hosalkar, Harish; Cameron, Danielle B; Heath, Aaron; David Horn, B; Ganley, Theodore J
Tibial tuberosity fractures in adolescents are uncommon. We retrospectively reviewed all tibial tuberosity fractures in adolescents (10-19) who presented to our level 1 pediatric trauma center over a 7-year period to review fracture morphology, mechanism of injury, fracture management including return to play, as well as complications. Additionally, we present a review of the literature and treatment algorithm. We reviewed the clinical charts and radiographs of consecutive patients with tibial tuberosity fractures between 01 January 2000 and 01 January 2007. Data parameters included the following: patients age and gender, involved side, injury classification, co-morbidities, mechanism of injury, treatment, return to activity and complications. Data were extracted and reviewed, and a treatment algorithm is proposed with some additional insights into the epidemiology of the injury. Nineteen patients met the inclusion criteria. There were 19 patients with 20 tibial tuberosity fractures. The mean age was 13.7 years. There were 18 males and 1 female patient. There were nine left-sided injuries and eleven right-sided including one patient with bilateral fractures. Mechanism of injuries included basketball injury (8), running injury (5), football injury (3), fall from a scooter (2), high jump (1) and fall (1). Co-morbidities included three patients with concurrent Osgood-Schlatter disease and one with osteogenesis imperfecta. All were treated with ORIF, including arthroscopic-assisted techniques in two cases. Complications included four patients with pre-operative presentation of compartment syndrome all requiring fasciotomy, one post-operative stiffness and one painful hardware requiring removal. Range of motion was started an average of 4.3 weeks post-operatively and return to play was an average of 3.9 months post-operatively. Although uncommon, tibial tuberosity fractures in adolescents are clinically important injuries. Early recognition and treatment (closed or open
Background and purpose Complications related to the fibula during distraction osteogenesis could cause malalignment. Most published studies have analyzed only migration of the fibula during lengthening, with few studies examining the effects of fibular complications. Patients and methods We retrospectively reviewed 120 segments (in 60 patients) between 2002 and 2009. All patients underwent bilateral tibial lengthening of more than 5 cm. The mean follow-up time was 4.9 (2.5–6.9) years. Results The average lengthening percentage was 34% (21–65). The ratio of mean fibular length to tibial length was 1.05 (0.91–1.11) preoperatively and 0.83 (0.65–0.95) postoperatively. The mean proximal fibular migration (PFM) was 15 (4–31) mm and mean distal fibular migration (DFM) was 9.7 (0–24) mm. Premature consolidation occurred in 10 segments, nonunion occurred in 12, and angulation of fibula occurred in 8 segments after lengthening. Valgus deformities of the knee occurred in 10 segments. Interpretation PFM induced valgus deformity of the knee, and premature consolidation of the fibula was associated with the distal migration of the proximal fibula. These mechanical malalignments could sometimes be serious enough to warrant surgical correction. Thus, during lengthening repeated radiographic examinations of the fibula are necessary to avoid complications. PMID:22329670
Hossin, B; Rizi, K; Murdan, S
We hypothesised that Hansen Solubility Parameters (HSPs) can be used to predict drug-nail affinities. Our aims were to: (i) determine the HSPs (δD, δP, δH) of the nail plate, the hoof membrane (a model for the nail plate), and of the drugs terbinafine HCl, amorolfine HCl, ciclopirox olamine and efinaconazole, by measuring their swelling/solubility in organic liquids, (ii) predict nail-drug interactions by comparing drug and nail HSPs, and (iii) evaluate the accuracy of these predictions using literature reports of experimentally-determined affinities of these drugs for keratin, the main constituent of the nail plate and hoof. Many solvents caused no change in the mass of nail plates, a few solvents deswelled the nail, while others swelled the nail to varying extents. Fingernail and toenail HSPs were almost the same, while hoof HSPs were similar, except for a slightly lower δP. High nail-terbinafine HCl, nail-amorolfine HCl and nail-ciclopirox olamine affinities, and low nail-efinaconazole affinities were then predicted, and found to accurately match experimental reports of these drugs' affinities to keratin. We therefore propose that drug and nail Hansen Solubility Parameters may be used to predict drug-nail interactions, and that these results can assist in the design of drugs for the treatment of nail diseases, such as onychomycosis and psoriasis. To our knowledge, this is the first report of the application of HSPs in ungual research.
Ong, Marcus Eng Hock; Chan, Yiong Huak; Oh, Jen Jen; Ngo, Adeline Su-Yin
Intraosseous (IO) access is an alternative to conventional intravenous access. The proximal tibia and proximal humerus have been proposed as suitable sites for IO access. A nonrandomized, prospective, observational study comparing flow rates and insertion success with tibial and humeral IO access in adults using the EZ-IO-powered drill device was conducted. The tibia was the first site of insertion, and a second IO was inserted in the humerus if clinically indicated for the same patient. Twenty-four patients were recruited, with 24 tibial and 11 humeral insertions. All EZ-IO insertions were successful at the first attempt except for 1 tibial insertion that was successful on the second attempt. All insertions were achieved within 20 seconds. Mean ease of IO insertion score (1=easiest to 10=most difficult) was 1.1 for both sites. We found tibial flow rates to be significantly faster using a pressure bag (165 mL/min) compared with those achieved without a pressure bag (73 mL/min), with a difference of 92 mL/min (95% confidence interval [CI]: 52, 132). Similarly, humeral flow rates were significantly faster using a pressure bag (153 mL/min) compared with humeral those achieved without pressure bag (84 mL/min), with a difference of 69 mL/min (95% CI: 39, 99). Comparing matched pairs (same patient), there was no significant difference in flow rates between tibial and humeral sites, with or without pressure bag infusion. Both sites had high-insertion success rates. Flow rates were significantly faster with a pressure bag infusion than without. However, we did not find any significant difference in tibial or humeral flow rates.
Tropet, Y; Garbuio, P; Obert, L; Jeunet, L; Elias, B
The purpose of this study was to report the authors' experience with emergency reconstruction of severe tibial shaft fractures. Five male patients were admitted to the emergency room with a grade IIIB open tibial shaft fracture with bone loss (average age, 33 years; age range, 18-65 years). Injuries were the result of motorcycle accidents (N = 2), pedestrian accidents (N = 1), gunshot wound (N = 1), and paragliding fall (N = 1). Primary emergent one-stage management for all patients consisted of administration of antibiotics, debridement, stabilization by locked intramedullary nailing, bone grafting from the iliac crest, and coverage using free muscle flaps (four latissimus dorsi and one gracilis). The average follow-up was 21 months (range, 8 months-3.5 years). Partial weight bearing with no immobilization was started at 3 months, and full weight bearing began 5 months after trauma. No angular complications and no nonunions were observed. There was one case of superficial infection without osteitis. All fractures healed within 6 months in 4 patients and within 10 months in 1 patient. At the last follow-up examination, ankle and knee motion was normal and no pain was noted, except for 1 patient who had associated lesions (ankle motion reduced by 50%). Aggressive emergency management of severe open tibial fractures provides good results. It improves end results markedly, not only by reducing tissue loss from infection, but also reducing healing and rehabilitation times.
Minoda, Yukihide; Kobayashi, Akio; Ikebuchi, Mitsuhiko; Iwaki, Hiroyoshi; Inori, Fumiaki; Nakamura, Hiroaki
In 21 knees receiving porous tantalum tibial component and 21 knees receiving a cemented cobalt-chromium tibial component, dual x-ray absorptiometry scans were performed for five years post-operatively. The postoperative decrease in the bone mineral density in the lateral aspect of the tibia was significantly less in knees with porous tantalum tibial components (11.6%) than in knees with cemented cobalt-chromium tibial components (29.6%) at five years (p < 0.05). No prosthetic migration or periprosthetic fracture was detected in either group. The present study is one of the studies with the longest follow-up period on bone mineral density after total knee arthroplasty. Porous tantalum tibial component has a favorable effect on the bone mineral density of the proximal tibia after total knee arthroplasty up to five years. Copyright © 2013 Elsevier Inc. All rights reserved.
Hallock, G G; Lutz, D A
Following nail bed repair, returning the nail plate as a conforming stent or splint is a common technique. Especially when split, the nail plate fragments can very readily be pieced together and bonded to the nail bed using the tissue adhesive Octyl-2-Cyanoacrylate. This new formulation can expedite this maneuver, and has shown no signs of histotoxicity or adverse effect on nail plate regeneration.
Abadi, Danielle; Zderic, Vesna
A novel ultrasound-mediated drug delivery system has been developed for treatment of a nail fungal disorder (onychomycosis) by improving delivery to the nail bed using ultrasound to increase the permeability of the nail. The slip-in device consists of ultrasound transducers and drug delivery compartments above each toenail. The device is connected to a computer, where a software interface allows users to select their preferred course of treatment. In in vitro testing, canine nails were exposed to 3 energy levels (acoustic power of 1.2 W and exposure durations of 30, 60, and 120 seconds). A stereo -microscope was used to determine how much of a drug-mimicking compound was delivered through the nail layers by measuring brightness on the cross section of each nail tested at each condition, where brightness level decreases coincide with increases in permeability. Each of the 3 energy levels tested showed statistical significance when compared to the control (P < .05) with a permeability factor of 1.3 after 30 seconds of exposure, 1.3 after 60 seconds, and 1.5 after 120 seconds, where a permeability factor of 1 shows no increase in permeability. Current treatments for onychomycosis include systemic, topical, and surgical. Even when used all together, these treatments typically take a long time to result in nail healing, thus making this ultrasound-mediated device a promising alternative.
Werner, Betina; Antunes, Andre
Nail clipping analysis for diagnosing causes of onychodystrophy other than onychomycosis is investigated to a very small extent. In order to achieve acceptance as a diagnostic method for any kind of nail abnormalities, normal microscopic parameters have to be established first. In most reported cases, nail plates were fixed in formalin with processing of the specimens with routine automated histotechnique. Fifteen pairs of normal nails were studied. One nail fragment was placed in a container with formalin, and the other was kept dry in a proper receptacle. Fixed specimens were submitted to standard automated tissue processing (formalin group) and dry specimens were directly embedded in paraffin (dry group). Several microscopic parameters were analyzed. Nail plate thickness ranged from 0.25 to 0.50 mm (mean 0.36 mm) and subungual region from 0 to 0.31 mm (mean 0.11 mm). Forty-one percent of cases presented onychokaryosis, and hypereosinophilic nuclear shadows were detected in 63%, statistically more frequent in the dry group (p=0.002). Parakeratosis was present in 86% of nails varying from 1 to 13 layers (mean 5.6). None of the nails presented fungi, neutrophils, and blood or serum collections. Bacteria were seen in 60% of specimens. Both groups yielded adequate microscopic preparations for analysis with no statistical difference in the dryness or hardness of specimens or difficulty in cutting the paraffin blocks (p=1). These microscopic findings of a normal population can be used as parameters for evaluating any cause of onychodystrophy. The dry method is faster and cheaper and yields adequate slide preparations for microscopic analysis of nail clippings.
Argintar, Evan; Martin, Benjamin D; Singer, Andrea; Hsieh, Adam H; Edwards, Scott
The main theoretic advantage of proximal olecranon fracture intramedullary fixation is decreased soft-tissue irritation and, potentially, less subsequent hardware removal. Despite this possible benefit, questions remain as to whether intramedullary devices are capable of controlling olecranon fractures to the same extent as locking plates. This study evaluates the ability of a novel multidirectional locking nail to stabilize comminuted fractures and directly compares its biomechanical performance with that of locking olecranon plates. We implanted 8 stainless steel locking plates and stainless steel intramedullary nails to stabilize a simulated comminuted fracture in 16 fresh-frozen cadaveric elbows. Flexion-extension, varus-valgus, gap distance, and rotational 3-dimensional angular displacement analysis was conducted over a 60° motion arc (30° to 90°) to assess fragment motion through physiologic cyclic arcs of motion and failure loading. Displacements in all planes were compared. Both implants showed less than 1° of motion in all measured planes and allowed less than 1 mm of gapping through all loads tested until ultimate failure. All failures occurred by sudden, catastrophic means. The mean failure weight for the nail was 14.4 kg compared with 8.7 kg for the plate (P = .02). The nail survived 1102 cycles, whereas the plate survived 831 cycles (P = .06). In simulated comminuted olecranon fractures, the multidirectional locking intramedullary nails sustained significantly higher maximum loads than the locking plates. The two implants showed no significant differences in fragment control or number of cycles survived. Surgeons can expect the multidirectional locking nails to stabilize comminuted fractures at least as well as locking plates. Copyright © 2012 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Mosby, Inc. All rights reserved.
Heyse, Thomas J; Tibesku, Carsten O
Patient-specific instrumentation (PSI) was introduced in an attempt to reduce positional outliers of components in total knee arthroplasty (TKA). It was hypothesized that PSI could help with the positioning of tibial components in optimal rotational alignment. A magnetic resonance imaging (MRI) analysis of 58 patients following TKA was conducted. Of these, 30 operations were performed using PSI and 28 using conventional instrumentation. The rotation of the tibial components was determined in MRI using three different reference lines: a tangent to the dorsal tibial condyles, the tibial epicondylar line, and the tibial tubercle. Deviations >9° were considered outliers. Also internal rotation >1° was considered an outlier. Data were analyzed statistically for positional outliers using the Chi-squared test. There was excellent inter- and intraobserver reliability with low standard deviations for the determination of tibial component rotation using the tangent to the dorsal condyles and the tibial epicondylar line as reference. Using the dorsal tangent as reference, there were eight components in excessive external rotation (28.6 %) and one component being in relative internal rotation (5.4°) in the conventional group, while there were two components in excessive external rotation in the PSI group (6.7 %). Using the tibial epicondyles as reference, there were seven components in excessive external rotation (21.4 %) and one component being in relative internal rotation (4.4°) in the conventional group; while there were two components in excessive external rotation in the PSI group (6.7 %). These differences were statistically significant (p < 0.05). Measurements based on the tibial tubercle showed poor reproducibility in terms of intra- and interobserver reliability and was of little use in the context of the research question. In this setup, PSI was effective in significantly reducing outliers of optimal rotational tibial component alignment during TKA. Anatomy of
Lee, Dong Hoon; Ryu, Keun Jung; Kim, Jae Hwa; Kim, Hae Hwa; Soung, Sahyun; Shin, Soowan
Opening-wedge high tibial osteotomy is a well-established procedure in the management of medial osteoarthritis of the knee and correction of proximal tibia vara. Recently, surgical approaches using less invasive plate osteosynthesis have been used with the goal of minimizing complications from more extensive soft tissue exposures. However, to our knowledge, less invasive fixator-assisted plate osteosynthesis has not been tested in the setting of opening-wedge high tibial osteotomy. The purposes of this study were (1) to assess the complications associated with use of a fixator-assisted less invasive plate osteosynthesis technique to stabilize an opening-wedge high tibial osteotomy in the treatment of proximal tibial vara; and (2) to evaluate the ability of this technique to achieve correction of the proximal tibial deformity and achieve osseous union. From June 2011 to June 2013, a total of 157 limbs in 83 patients who underwent fixator-assisted high tibial osteotomy for (1) idiopathic genu vara; or (2) osteoarthritis of the knee with proximal tibia vara were initially enrolled. Of these, eight limbs (5%) were excluded on the way; thus, 149 limbs in 77 patients were evaluated. During the period in question, no other techniques were used for proximal tibial osteotomy. The surgical procedures included less preparation of soft tissue, proximal tibial osteotomy, application of a temporary external fixator, correction of alignment, and final fixation with the help of an external fixator. Complications were assessed by chart review and the alignment in both coronal and sagittal planes was compared pre- and postoperatively. Radiographic review to confirm osseous union and alignment was performed by two of the authors not involved in clinical care of the patient. Delayed union was described as union occurring later than 4 months. Thirty limbs out of 149 tibiae (20%) showed complications, all of which were resolved without leaving any sequela. Twenty-seven limbs out of 149
Benedetto, Karl Peter; Hoffelner, Thomas; Osti, Michael
The hypothesis of the present study was that the biomechanical properties of arthroscopic tibial inlay procedures depend on tibial graft bone block position. Five paired fresh-frozen human cadaveric knee specimens were randomized to a reconstruction with quadriceps tendon placing the replicated footprint either to the more proximal margin of the remnants of the anatomical PCL fibrous attachments (group A) or to the distal margin of the anatomical PCL fibrous attachments at the edge of the posterior tibial facet to the posterior tibial cortex in level with the previous physis line (group B). The relative graft-tibia motions, post cycling pull-out failure load and failure properties of the tibia-graft fixation were measured. Cyclic displacement at 5, 500 and 1,000 cycles, stiffness and yield strength were calculated. The cyclic displacement at 5, 500 and 1,000 cycles measured consistently more in group A without statistically significant difference (4.11 ± 1.37, 7.73 ± 2.73 and 8.18 ± 2.75 mm versus 2.81 ± 1.33, 6.01 ± 2.37 and 6.46 ± 2.37 mm). Mean ultimate load to failure (564.6 ± 212.3) and yield strength (500.2 ± 185.9 N) were significantly higher in group B (p < 0.05). Replicating the anatomical PCL footprint at the posterior edge of the posterior tibial facet yields higher pull-out strength and less cycling loading displacement compared to a tunnel position at the centre of the posterior tibial facet.
Kim, Stanley E; Pozzi, Antonio; Banks, Scott A; Conrad, Bryan P; Lewis, Daniel D
Objective- To evaluate the effects of tibial tuberosity advancement (TTA) on femorotibial contact mechanics and 3-dimensional kinematics in cranial cruciate ligament (CrCL)-deficient stifles of dogs. Study Design- In vitro biomechanical study. Animals- Unpaired pelvic limbs from 8 dogs, weighing 28-35 kg. Methods- Digital pressure sensors placed subjacent to the menisci were used to measure femorotibial contact force, contact area, peak and mean contact pressure, and peak pressure location with the limb under an axial load of 30% body weight and a stifle angle of 135 degrees . Three-dimensional static poses of the stifle were obtained using a Microscribe digitizing arm. Each specimen was tested under normal, CrCL-deficient, and TTA-treated conditions. Repeated measures analysis of variance with a Tukey post hoc test (P<.05) was used for statistical comparison. Results- Significant disturbances to all measured contact mechanic parameters were evident after CrCL transection, which corresponded to marked cranial tibial subluxation and internal tibial rotation in the CrCL-deficient stifle. No significant differences in any contact mechanic and kinematic parameters were detected between normal and TTA-treated stifles. Conclusion- TTA eliminates craniocaudal stifle instability during simulated weight-bearing and concurrently restores femorotibial contact mechanics to normal. Clinical Relevance- TTA may mitigate the progression of stifle osteoarthritis in dogs afflicted with CrCL insufficiency by eliminating cranial tibial thrust while preserving the normal orientation of the proximal tibial articulating surface.
Schwartz, Adam J; Ravi, Bheeshma; Kransdorf, Mark J; Clarke, Henry D
A standing anteroposterior (AP) radiograph is commonly used to evaluate coronal alignment following total knee arthroplasty (TKA). The impact of coronal alignment on TKA outcomes is controversial, perhaps due to variability in imaging and/or measurement technique. We sought to quantify the effect of image rotation and tibial slope on coronal alignment. Using a standard extramedullary tibial alignment guide, 3 cadaver legs were cut to accept a tibial tray at 0°, 3°, and 7° of slope. A computed tomography scan of the entire tibia was obtained for each specimen to confirm neutral coronal alignment. Images were then obtained at progressive 10° intervals of internal and external rotation up to 40° maximum in each direction. Images were then randomized and 5 blinded TKA surgeons were asked to determine coronal alignment. Continuous data values were transformed to categorical data (neutral , valgus [L], and varus [R]). Each 10° interval of external rotation of a 7° sloped tibial cut (or relative internal rotation of a tibial component viewed in the AP plane) resulted in perception of an additional 0.75° of varus. The slope of the proximal tibia bone cut should be taken into account when measuring coronal alignment on a standing AP radiograph. Copyright © 2017 Elsevier Inc. All rights reserved.
Snorrason, Ivar; Woods, Douglas W
Nail picking disorder (onychotillomania) is characterized by excessive picking or pulling at one's own finger- or toenails. This condition has received scant research attention and may be related to other body focused repetitive behaviors such as pathological nail biting, skin picking and hair pulling. We present a case of a male client with a chronic and severe nail picking habit treated with acceptance-enhanced behavior therapy. The client showed clinical characteristics similar to other body focused repetitive behaviors and responded moderately well to the treatment. Copyright © 2013 Elsevier Ltd. All rights reserved.
Webb, Justin M; Salmon, Lucy J; Leclerc, Etienne; Pinczewski, Leo A; Roe, Justin P
An injury to the anterior cruciate ligament (ACL) is a multifactorial event influenced by intrinsic and extrinsic risk factors. Recently, the geometry of the proximal tibia has come under focus as a possible risk factor for an ACL injury. An increased posterior tibial slope is associated with an increased risk of further ACL injuries in the previously ACL-reconstructed patient. Case-control study; Level of evidence, 3. A total of 200 consecutive patients with isolated ACL ruptures who underwent primary reconstruction with hamstring autografts were enrolled in a prospective longitudinal study over 15 years. The posterior tibial slope was measured from a lateral knee radiograph by 2 blinded observers. The data were analyzed for the association between an increased posterior tibial slope and the incidence of further ACL injuries. Interobserver reliability of the posterior tibial slope measurements was assessed. Radiographs and follow-up were available for 181 of the 200 enrolled patients. Fifty patients had a further injury to either the ACL graft or the contralateral knee. The mean posterior tibial slope of those with a further ACL injury was 9.9° compared with 8.5° for those with no further injury (P = .001). The mean posterior tibial slope for those with both an ACL graft and contralateral ACL rupture was 12.9°. The odds of further ACL injuries after reconstruction were increased by a factor of 5, to an incidence of 59%, in those with a posterior tibial slope of ≥12°. An increased posterior tibial slope is associated with increased odds of a further ACL injury after ACL reconstruction. The increased risk is most pronounced in those with a posterior tibial slope of ≥12°.
Zhu, Guang-Duo; Guo, Wan-Shou; Zhang, Qi-Dong; Liu, Zhao-Hui; Cheng, Li-Ming
Background: Controversies about the rational positioning of the tibial component in unicompartmental knee arthroplasty (UKA) still exist. Previous finite element (FE) studies were rare, and the results varied. This FE study aimed to analyze the influence of the tibial component coronal alignment on knee biomechanics in mobile-bearing UKA and find a ration range of inclination angles. Methods: A three-dimensional FE model of the intact knee was constructed from image data of one normal subject. A 1000 N compressive load was applied to the intact knee model for validating. Then a set of eleven UKA FE models was developed with the coronal inclination angles of the tibial tray ranging from 10° valgus to 10° varus. Tibial bone stresses and strains, contact pressures and load distribution in all UKA models were calculated and analyzed under the unified loading and boundary conditions. Results: Load distribution, contact pressures, and contact areas in intact knee model were validated. In UKA models, von Mises stress and compressive strain at proximal medial cortical bone increased significantly as the tibial tray was in valgus inclination >4°, which may increase the risk of residual pain. Compressive strains at tibial keel slot were above the high threshold with varus inclination >4°, which may result in greater risk of component migration. Tibial bone resection corner acted as a strain-raiser regardless of the inclination angles. Compressive strains at the resected surface slightly changed with the varying inclinations and were not supposed to induce bone resorption and component loosening. Contact pressures and load percentage in lateral compartment increased with the more varus inclination, which may lead to osteoarthritis progression. Conclusions: Static knee biomechanics after UKA can be greatly affected by tibial component coronal alignment. A range from 4° valgus to 4° varus inclination of tibial component can be recommended in mobile-bearing UKA. PMID
Huang, Shucheng; Zhang, Lihong; Rehman, Mujeeb Ur; Iqbal, Muhammad Kashif; Lan, Yanfang; Mehmood, Khalid; Zhang, Hui; Qiu, Gang; Nabi, Fazul; Yao, Wangyuan; Wang, Meng; Li, Jiakui
Tibial dyschondroplasia (TD) is one of the most common problems in the poultry industry and leads to lameness by affecting the proximal growth plate of the tibia. However, due to the unique environmental and geographical conditions of Tibet, no case of TD has been reported in Tibetan chickens (TBCs). The present study was designed to investigate the effect of high altitude hypoxia on blood parameters and tibial growth plate development in chickens using the complete blood count, morphology, and histological examination. The results of this study showed an undesirable impact on the overall performance, body weight, and mortality of Arbor Acres chickens (AACs) exposed to a high altitude hypoxic environment. However, AACs raised under hypoxic conditions showed an elevated number of red blood cells (RBCs) and an increase in hemoglobin and hematocrit values on day 14 compared to the hypobaric normoxia group. Notably, the morphology and histology analyses showed that the size of tibial growth plates in AACs was enlarged and that the blood vessel density was also higher after exposure to the hypoxic environment for 14 days, while no such change was observed in TBCs. Altogether, our results revealed that the hypoxic environment has a potentially new role in increasing the blood vessel density of proximal tibial growth plates to strengthen and enhance the size of the growth plates, which may provide new insights for the therapeutic manipulation of hypoxia in poultry TD.
Huang, Shucheng; Zhang, Lihong; Rehman, Mujeeb Ur; Iqbal, Muhammad Kashif; Lan, Yanfang; Mehmood, Khalid; Zhang, Hui; Qiu, Gang; Nabi, Fazul; Yao, Wangyuan; Wang, Meng; Li, Jiakui
Tibial dyschondroplasia (TD) is one of the most common problems in the poultry industry and leads to lameness by affecting the proximal growth plate of the tibia. However, due to the unique environmental and geographical conditions of Tibet, no case of TD has been reported in Tibetan chickens (TBCs). The present study was designed to investigate the effect of high altitude hypoxia on blood parameters and tibial growth plate development in chickens using the complete blood count, morphology, and histological examination. The results of this study showed an undesirable impact on the overall performance, body weight, and mortality of Arbor Acres chickens (AACs) exposed to a high altitude hypoxic environment. However, AACs raised under hypoxic conditions showed an elevated number of red blood cells (RBCs) and an increase in hemoglobin and hematocrit values on day 14 compared to the hypobaric normoxia group. Notably, the morphology and histology analyses showed that the size of tibial growth plates in AACs was enlarged and that the blood vessel density was also higher after exposure to the hypoxic environment for 14 days, while no such change was observed in TBCs. Altogether, our results revealed that the hypoxic environment has a potentially new role in increasing the blood vessel density of proximal tibial growth plates to strengthen and enhance the size of the growth plates, which may provide new insights for the therapeutic manipulation of hypoxia in poultry TD. PMID:28282429
Rao, Biyyam; Kamal, Tamer
Osteonecrosis of the knee is a well-described cause of acute knee pain. It can lead to significant functional impairment, rapid arthritic joint changes and subsequent collapse. Several hypotheses exist different treatment options are used ranging from conservative management to joint arthroplasty. The majority of cases involve the distal femoral condyle and to a much lesser extent the medial tibial plateau. We are presenting a rare case of osteonecrosis of the proximal tibia affecting the lateral tibial condyle in 44 years old Caucasian male which was treated successfully using osteonecrotic tantalum rods with 26 month follow-up.
Rao, Biyyam; Kamal, Tamer
Osteonecrosis of the knee is a well-described cause of acute knee pain. It can lead to significant functional impairment, rapid arthritic joint changes and subsequent collapse. Several hypotheses exist different treatment options are used ranging from conservative management to joint arthroplasty. The majority of cases involve the distal femoral condyle and to a much lesser extent the medial tibial plateau. We are presenting a rare case of osteonecrosis of the proximal tibia affecting the lateral tibial condyle in 44 years old Caucasian male which was treated successfully using osteonecrotic tantalum rods with 26 month follow-up. PMID:25983460
Olszewska, Malgorzata; Wu, John Z; Slowinska, Monika; Rudnicka, Lidia
All-in-one devices with mobile phone, web browser, and organizer are now owned by over 6 million people and their popularity is increasing. These devices are often called personal digital assistants (PDAs) or 'BlackBerry(R)' devices, after a popular brand name of these appliances. The use of PDAs is associated with exposure of distal thumbs and nails to repeated pressure with a frequency of up to a few thousand times per hour and several tens of thousands of times per day. We describe two cases of traumatic thumb nail dystrophy associated with using a PDA keyboard for several hours per day. Both patients developed median nail plate dystrophy after 4-8 months of habitual PDA use. One patient also developed thumb nail psoriasis and paronychia. All symptoms resolved a few months after discontinuing PDA use. Analysis of nail biomechanics, performed by using a finite element fingertip model, showed that maximal stress reaches approxi